OVAR/GEC Interdisciplinary Transitions in Responsibility for Aging Care

Almost daily there are stories of older persons who are at great risk due to the failure of health care providers and the health care system to adequately transfer the responsibility for their care. Examples could include older persons who are discharged from the hospital without instructions for self-care nor plans for home health or with an inadequate supply of pain medicine for the weekend; those who do not know what medications they should be taking, how much or why; those who need community mental health services but do not know what is available; those living in nursing homes with CNAs who are untrained in dementia care; those with family caregivers without the necessary skills to change dressings or manage bed-sores; or those who go from the emergency room, to the x-ray department, to the orthopedic clinic to physical therapy and complete forms at every stop to provide the same information. As these examples show, frail older people may receive care in multiple settings from multiple health care providers and caregivers. Care may be transferred numerous times among family and/or home health providers, general practitioners and specialists, emergency rooms, intensive care units, acute hospitals, rehabilitation centers, nursing homes, and hospice. Within each of these settings the responsibility for care may transfer to numerous different departments and interdisciplinary professionals without benefit of information, medical records, and preferences/instructions for care. The problems inherent in interdisciplinary transferences of aging care are multiplied in the OV ARJGEC region because rural Appalachian elderly are more likely to be poor and less educated, to operate in physical and social isolation, and to have access to health care delivery systems that have only approximated what is necessary to provide high quality health promotion and health care. OV AR needs assessments conducted in 2003-2004 provided documentation that health care faculty, students, and geriatrics services providers require resources, curricula, replicable programs, and training on interdisciplinary transitions in responsibilities of aging care, especially in the areas of Alzheimer's disease, chronic conditions, pain management, end of life care, emergency care, health literacy and cultural diversity.