1. Description of Interventions for Transition Care for the post-acute and long term care (PA/LTC) setting

PA/LTC to home, PA/LTC to ED/hospital, and ED/hospital to PA/LTC

• What are the risks of ineffective transitions of care?
• What are the goals of transition care?
• What are the common components of effective transition care interventions or processes for the PA/LTC setting?

2. Description of the Context for Implementing Transition Care

• What are the resources needed to implement transition care?
• What are the specific barriers to implementing transition care or processes for PA/LTC?
• Who delivers transition interventions and what training is required to implement identified approaches to transition care for PA/LTC?

3. Description of the Existing Evidence (Evidence Map)

• Which patient groups/clinical conditions are represented in studies on the use and evaluation of transition care for PA/LTC?
• Which patient groups/clinical conditions are at greatest risk of poor outcomes during transition care in PA/LTC?
• What outcomes are measured in studies on the use and evaluation of transition care for PA/LTC?

4. What are the effects of different financial / reimbursement models (i.e. Accountable Care Organizations) on Transition Care?

Optimal transitions of care (ToC) centered on the post-acute and long term care (PA/LTC) setting influence the quality and costs of care for a vulnerable, often older, adult population. Medicare and Medicaid cover much of the costs associated with care in the PA/LTC setting. These transitions include: hospital/emergency department (ED) to PA/LTC, PA/LTC to ED/hospital and PA/LTC to home. There are more than 14,000 nursing homes in the United States with more than 3 million vulnerable individuals remaining in, or passing through, these many facilities in a year. A systematic review could highlight the most beneficial approaches to optimizing ToC.

AMDA - The Society for Post-acute and Long Term Care Medicine (AMDA PA/LTC) is the national professional organization supporting optimization of care in the PA/LTC setting. One of the means whereby AMDA PA/LTC supports providers and interdisciplinary teams in providing optimal care to the vulnerable population they support is through Clinical Practice Guidelines. The performance of systematic reviews to support such guidelines is imperative in this age of and explosion of new knowledge. The questions put forward in this request will inform the AMDA PA/LTC Transitions of Care Clinical Practice Guideline.

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

I am a physician practicing geriatric medicine and hospice and palliative medicine with a focus on care in the post-acute care setting. My core appointment is at Michigan Medicine in Ann Arbor and my clinical activity is at VA Ann Arbor Healthcare System. This request is motivated through my new role as chairman of the AMDA PA/LTC Clinical Practice Guideline and Tools subcommittee of the Clinical Practice Committee. Our subcommittee is embarking next on the development of a contemporary Transitions of Care Clinical Practice Guideline.

If you are you making a suggestion on behalf of an organization, please state the name of the organization

AMDA- The Society for Post-acute and Long Term Care Medicine

Please tell us how you heard about the Effective Health Care Program

The Effective Health Care Program is well-known and respected within our committee and subcommittee.