Unsuccessful transitions of care may be life threatening to the elderly population. In addition, patients admitted into hospitals may develop a dependence upon the hospital services that addressed their needs; however, upon discharge to home, patients and caregiver and expected to assume a self-management role with little support or preparation. At home, caregivers may not be able to provide the proper care necessary to ensure a safe transition.3 This can lead to negative impacts on the patient without support system to help with their transition.
The current health care system does not provide the important elements to effective transitions of care. Instead, it has produced challenges for patients and health care providers. One challenge is that many practitioners are deemed as “silos” of care, where there is limited