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5~, <br />Transitions: what are the issues: <br />Relocation trauma and the adverse effects is well documented. and is a part of every <br />transition, <br />Issues in transitions can start with the well elderly moving to independent senior housing <br />and retirement communities <br />Transitions within a CCRC: when to transfer /when not, legal latitude - if you transfer <br />against resident desires it can be seen as a breach of resident rights; if you don't <br />transfer and something happens, can be sued for negligence: what's the solution? <br />Regulations cause us to deliver in silo style of service rather than seamless continuum - <br />very prescriptive on what we can and cannot deliver <br />Hospitals discharging medically complicated persons sooner, lack of appropriate follow- <br />up and lack of support services results in high probability of re-admission; there is <br />an absence of adequately finance Home and Community Based services to <br />respond to seniors after hospitalization. Many may no longer be acute but yet not <br />independent and many lank the informal support system necessary to heal. <br />Medicaze/Medicaid pay for medical intervention not prevention <br />Transfers are being made to the ER that might be avoided with better assessment <br />incentives <br />Hospice and palliative caze are not core competencies of hospitals <br />What national aspect(s) does AALISA needs to address: <br />1. Transitions within L,TC: are they resident centered - how to measure that <br />decisions are being made to assure a person in the least restrictive environment <br />getting the most appropriate level of service, while assuring safety, How does one <br />balance personal choice with cost and availability of staff? How can policy, <br />regulation, payment source and quality service come into alignment allowing <br />flexibility? <br />2.. In hospital settings, reimbursement pressures prompt discharge of patients sooner. <br />Complex peripheral needs make an immediate return home difficult (just the <br />physical task of securing transportation to get home can he difficult). In adequate <br />communication by caregivers [doctors, nurses, social workers, etc] at the point of <br />dischazge. The community services are fragmented particularly challenging for <br />elders who do not have advocates negotiating the maze. Receiving uncoordinated <br />Gaze places them at risk of medical error, adverse effect of pharmacology, <br />inability to physically get to follow-up visits, and other such complications can <br />result in costly re-admission to the hospital. Traditionally payment is only for <br />services within the medical model rather than addressing a less costly support <br />service model and more attention to discharge planning and transition <br />management <br />How are ER's being used? Using ER's as service respondents for those who are <br />recipients of inadequate assessments is a very costly option.. What aze the reasons <br />that elderly being transferred to ER? Gould better assessments, negotiated risk <br />agreements, and physician response decrease this costly (monetarily and <br />emotionally, sometimes physically) costly transition.. <br />