Frail older adults receiving long-term services and supports (LTSS) in their own homes, assisted living facilities (ALFs), and skilled nursing facilities or nursing homes (SNFs/NHs) are among the most vulnerable of patient groups. When they require acute hospitalizations, they must navigate a fragmented system with poor “handoffs,” often resulting in negative outcomes. Reducing preventable hospitalizations and improving transitions to and from hospitals will enhance health care quality and outcomes among these elders.

In a qualitative study, Toles and colleagues identified barriers and facilitators to high-quality care to support older adults through these care transitions. They found that LTSS recipients and family caregivers do not receive needed information about the reasons for their transfers to hospitals, medical diagnoses, and planned treatments to address acute changes in health. Findings indicate an urgent need for nurses and other health care team members to engage and inform LTSS recipients (and family caregivers), as well as the need for research to test evidence-based transitional care for high-risk LTSS recipients and their family caregivers.