Failure at the transition of care: Challenges in the discharge of the vulnerable elderly patient
Abstract
The case of an elderly patient with mild dementia and severe depression is reviewed including analysis of the barriers to successful transition that led to readmission. Situations likely to result in failed transitions include poor social support, discharge during times when ancillary services are unavailable, uncertain medication reconciliation, depression, and patients' cognitive limitations. Evidence suggests deficits in communication by hospital physicians to primary care providers occur commonly but this is only one of many systems barriers to successful discharge. Review of the literature reveals interventions such as involvement of advance practice nurses or family members in the transition may overcome some of the difficulties inherent in discharge of the vulnerable geriatric patient. Weekend discharges present unique challenges and potential solutions are explored. This case offers the opportunity to review the elements necessary for success and insight into the systems limitations which underlie failed transitions. Journal of Hospital Medicine 2008;3:349–352. © 2008 Society of Hospital Medicine.
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Inconsistencies in the standard of care from admission and during the hospital stay were associated with reduced patient wellbeing and potential inequitable access to care, which increased the risk of readmission.
“Inconsistencies in the standard of care from admission and during the hospital stay (potentially explained in part by a lack of standardised information exchange) were associated with reduced patient wellbeing and potential inequitable access to care, which increased the risk of readmission [28, 39–43].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [40]
Collaboration between healthcare professionals was associated with delayed discharges, emphasising the problem in care co-ordination.
“As a result, collaboration between HCPs was associated with delayed discharges, emphasising the problem in care co-ordination (CMOC19) [40, 42, 74, 83, 88, 91, 92].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [40]
Feelings of obligation influenced acceptance of the carer role.
“Feelings of obligation influenced acceptance of the carer role; cultural norms, in which family members typically look after their elder relatives, likely contributed to this, as expectations were stronger for closer relatives (e.g. children) to assume responsibility for care (CMOC25) [40, 46].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [40]
Cultural norms likely contributed to feelings of obligation, as expectations were stronger for closer relatives to assume responsibility for care.
“Feelings of obligation influenced acceptance of the carer role; cultural norms, in which family members typically look after their elder relatives, likely contributed to this, as expectations were stronger for closer relatives (e.g. children) to assume responsibility for care (CMOC25) [40, 46].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [40]
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- Authors
- Cumbler, E., Carter, J., & Kutner, J.
- Affiliations
- University of Colorado Denver (US)
- Venue
- Journal of Hospital Medicine
- Publisher
- Wiley
- Published
- 2008-07
- Volume
- 3
- Issue
- 4
- Pages
- 349-352
- ISSN
- 1553-5592 (ISSN-L)
- 1553-5606
- OpenAlex
- W2027112061
- Cited by
- 38
- References
- 11
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 1 · 2021: 1 · 2020: 3 · 2018: 2 · 2017: 4 · 2015: 5 · 2014: 3 · 2013: 6 · 2012: 7
- FWCI
- 1.46
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Hospital Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Health Sciences › Health Professions › Speech and Hearing › Adolescent and Pediatric Healthcare
- Keywords
- care transitions, hospital discharge, elderly patients, mild dementia, depression, hospital readmission, medication reconciliation, social support, ancillary services, physician-physician communication, advanced practice nurses, family involvement, weekend discharge, elderly care
- MeSH terms
- Aged, 80 and over, Continuity of Patient Care, Dementia, Major Depressive Disorder, Female, Home Care Services, Humans, Medication Errors, Patient Discharge, Patient Education as Topic, Patient Readmission, Vulnerable Populations
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