Care Transitions

Care transitions happen when an individual moves from one setting or location of care to another. These transitions can put older adults at risk for health issues, including malnutrition, but planning can help ensure that older adults and caregivers have the resources they need to transition safely. Meals and other nutrition services can be vital to successful care transitions. Understanding transitions can help you expand your program’s reach.

Guides

Addressing Malnutrition in Older Adults During Care Transitions—MOWA
guide to understanding the impact of transitions across care settings and the risk of malnutrition
due to physiological, psychosocial, and economic factors
- Report
Evaluating Malnutrition Care Coordination for Successful Patient Transitions— Resource from
the Academy of Nutrition and Dietetics on advancing malnutrition care through adoption of electronic clinical quality measures
Partnering to Integrate Health and Long-Term Care— Data and
early evidence from the Aging and Disability Business Institute on how community-based organizations partner with health care organizations

Fact Sheets

Better Integration of Malnutrition Care into Care Transitions is Necessary— Resource from the Academy of Nutrition and Dietetics, Avalere Health, and Defeat Malnutrition Today on integrating malnutrition care with care transitions

Tools & Toolkits

Care Transitions Intervention Toolkit— Aging and Disability Resource Centers toolkit made to supplement the Care Transition Intervention model

Presentations

Care Transitions Intervention for Older Adults— JASA presentation on integrating health care and social services to address the social determinants of health; reduce hospital readmissions; and ensure stable, home-based functioning

Resources

Evidence-Based Care Transitions Program — Information from ACL about Aging and Disability Resource Center programs

Research

Improving Integration of Malnutrition Care in Care Transitions— Information from the Academy of Nutrition and Dietetics about a national dialogue and pilot studies