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Project Details

From Hospital to Home: Improving Transitional Care for Older Adults

Photo for "From Hospital to Home" Project
Project Summary: 

Care transitions are a significant health and social problem for seniors and their caregivers. Many seniors experience breakdowns in care during the transition from hospital to home, resulting in poor health outcomes and high rehospitalization rates. Health Research for Action (HRA) conducted a strategic analysis of issues related to seniors’ transitions, including doing a comprehensive review of existing research and conducting focus groups and interviews with caregivers, providers, and policymakers. With an advisory group, the project made comprehensive recommendations for change.

Main Findings: 

The project identified ways to improve hospital-to-home transitions for seniors and for their caregivers:

  • Interventions to educate seniors and their caregivers
  • Improved access to community resources
  • Provider training to improve discharge planning and follow-up
  • Systems and policy-level changes
Policy, Practice or Research Impacts: 

This was one of the most comprehensive assessments to date of issues related to hospital-to-home transitions for seniors. It identified many important actions to improve transitional care through interventions to empower seniors and their caregivers. As follow-up, HRA hosted a Transitional Care Leadership Summit that brought together national experts to discuss innovations and policy recommendations.

Contact Person: 
Holly Brown- Williams
Contact Person's Email Address:
Health Research for Action, UC Berkeley
Principal Investigators: 
Professors S.Leonard Syme and Linda Neuhauser
Research Publications and Reports: 

From Hospital to Home: Improving Transitional Care for Older Adults, a summary report of key research findings and recommendations. 2006
From Hospital to Home: A Strategic Assessment of Eldercare in the San Francisco Bay Area, Review of Literature. 2005

community advisory board, over 30 community organizations, the American Society on Aging, and UC Berkeley’s Center for Advanced Study of Aging Services
Gordon and Betty Moore Foundation
Publication Date: