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Friday, March 23 • 11:00am - 12:00pm
FR2 | Are we Doing Enough? A Need for New Approaches to Address Transitions of Care for the Older Adults Across Continuum of Care

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This session will discuss key factors leading to ineffective care transitions, emphasize the need for a new approach to delivering transitional care, and describe an integrated approach to achieve optimal transitional care. This approach is based on best practices of different models of care transitions and has not been implemented yet. It has seven key elements based on factors that can help achieve effective care transitions: (1) effective communication among providers; (2) discussion of goals of care and advance directives; (3) functional assessment; (4) medication reconciliation; (5) co-ordination and effective implementation of a care plan; (6) timely and quality discharge summaries; (7) patient-centered instructions and risk-related education.

Learning Objectives:
(1) Implement key elements of an effective care transitions into patient care.
(2) Establish strong communication and collaboration with community physicians, and hospital, and home care teams to provide optimal patient care during care transitions.
(3) Implement strategies for effective communication with patients, families and care teams during care transitions.

avatar for Fatima Sheikh, MD, MPH, CMD

Fatima Sheikh, MD, MPH, CMD

Fatima Sheikh, MD, MPH, CMD, is medical director of multiple skilled nursing/long-term care facilities in Baltimore. She was trained at Johns Hopkins School of Medicine in Geriatrics and currently holds a part-time faculty position as assistant professor with Geriatric Medicine Department... Read More →
avatar for Michele Bellantoni, MD, CMD

Michele Bellantoni, MD, CMD

Michele Bellantoni, MD, CMD, is an Associate Professor of Medicine and Clinical Director of the Division of Geriatric Medicine and Gerontology at the Johns Hopkins University School of Medicine. She serves as Medical Director of the Specialty Hospital Programs of the Johns Hopkins... Read More →
avatar for Alicia Arbaje, MD, MPH, PHD

Alicia Arbaje, MD, MPH, PHD

Alicia Arbaje, MD, MPH, PhD, is Associate Professor of Medicine and Director of Transitional Care Research. She is based at the Center for Transformative Geriatrics Research at Johns Hopkins School of Medicine. She is leading several studies that aim to develop performance measures... Read More →

Friday March 23, 2018 11:00am - 12:00pm EDT
Texas 1-2
  Models of Care