Active Roles for Older Adults in Navigating Care Transitions: Lessons Learned from the Care Transitions Intervention

ABSTRACT

Older persons suffer from complex and chronic health conditions that require ongoing self-care activities as well as management by health care professionals. Older adults commonly receive care in multiple settings (hospital, skilled nursing facility, ambulatory clinic, home) necessitating transitions between settings of care. Multiple strategies have been proposed to aid care coordination between settings of care. However, most rely upon changing the way in which roles for health professionals are structured or function and do not acknowledge the significant role patients and family caregivers play in navigating their transitions. An alternative approach, health coaching, seeks to impart the skills and confidence needed for patients to assure their needs are met, and thus enacts a patient-centered approach to problems in care coordination. Here, we use an intervention with proven efficacy (The Care Transitions Intervention) to explore transition coaching as a specific form of health coaching used to empower older adults in navigating care transitions; we discuss the mechanisms and techniques involved in enacting an empowerment-based intervention; and finally, we discuss the approaches and contextual issues involved in training selected members of the existing health care workforce in a transition coaching model

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