Bridging the Gaps: Transition of Care for the Older Adult

June 25, 2015

There are currently more adults 65 years or older in the United States than at any other time in history. However, significant challenges remain when it comes to the coordination and continuity of healthcare as this patient population transfers between different locations or levels of care during the course of a chronic or acute illness. Transition of care for the older adult includes incorporating a team-based approach to coordinate care for patients with complex medical conditions; assisting them through navigation of the complexities of the healthcare system; and recognizing the importance of family and caregiver involvement to promote continuity of care. A successful care transition can improve quality of life for older adults through improved health outcomes, reduction in preventable hospital readmissions, and a reduction in total healthcare costs. This activity is designed to equip healthcare providers (HCPs) with the skills to help bridge the gaps in care transition for the older adult from one clinical setting to another and enable clinicians to be prepared to care for this patient population.

Learning Objectives
At the end of this educational activity, participants should be able to

  1. Summarize the meaning of care transition for the older adult
  2. Review different care transition models and how they impact the older adult’s quality of life
  3. Discuss the importance of caregiver involvement and HCPs’ roles in care transition
  4. Recognize the impact of effective transition of care on improving health outcomes and reducing healthcare costs

Alicia I. ArbajeoAlicia I. Arbaje, MD, MPH
Assistant Professor of Medicine
Director of Transitional Care Research
Division of Geriatric Medicine and Gerontology
Johns Hopkins University School of Medicine
Core Faculty
Center for Innovative Care in Aging
Johns Hopkins University School of Nursing
Baltimore, Maryland

About the Presenter
Alicia I. Arbaje, MD, MPH, is Assistant Professor, Division of Geriatric Medicine and Gerontology, and Director of Transitional Care Research at Johns Hopkins University. She is board certified in geriatric medicine. Her focus is on the difficulties older adults face as they navigate through the healthcare system. Specifically, Dr. Arbaje’s research concentrates on developing performance measures and best practices to improve the quality of care delivered during the older adults’ transitions across healthcare settings, e.g., from hospital to home. She has been invited to share her expertise with the Centers for Medicare and Medicaid Services (CMS), the Agency for Healthcare Research and Quality (AHRQ), NBC Nightly NewsCNN International, and Good Morning Maryland (WMAR-TV), along with various Spanish-language media outlets and international conferences on aging.

Disclosures of Relevant Financial Relationships
In accordance with the ACCME Standards for Commercial SupportSM, OptumHealth Education requires all those involved in the development of activity content to disclose their relevant financial relationships. An individual has a relevant financial relationship if such person (or their spouse/partner) has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the activity content over which the individual has control.
OptumHealth Education ensures that the content is independent of commercial bias.

Faculty Disclosure
Alicia I. Arbaje, MD, MPH has indicated that she has no relevant financial relationships.

Activity Planners
Sarah Chart-Hart, RN
Senior Director
OptumHealth Education

Arlene Rome, RN, BSN
Activity Manager
OptumHealth Education

Activity Planner Disclosures
All of the planners reported that they are employees of and own stock in UnitedHealth Group.

Reviewer Disclosures
To ensure fair balance and avoid bias, the content for this activity has been reviewed by an independent medical expert with no relevant financial relationships.

Method of Participation
There are no fees for participating in or receiving credit for this activity.
For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

Participants will receive a certificate upon successful completion of the activity, which includes the following:

  • Completing the entire activity
  • Completing the Pre- and Post-Activity Assessments, Activity Evaluation, and Application for Certificate of Credit forms

You must be logged into your account to participate in this activity. Get started by clicking “Begin” and viewing the “CE Info”; then follow the prompts at the bottom of the screen. At the end of the activity, you will be able to view, save, or print your certificate of participation. The Area of Practice you indicated in your profile corresponds with your certificate type. A complete listing of all of your activities can be found under “My Account”, “My Activities.”

Accreditation Statement
OptumHealth Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.

Credit Designation Statements
OptumHealth Education designates this live activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physician Assistants
The American Academy of Physician Assistants (AAPA) accepts credit from organizations accredited by the ACCME.

The participant will be awarded up to 1.00 contact hour(s) of credit for attendance and completion of supplemental materials.

Nurse Practitioners
The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts credit from organizations accredited by the ACCME and ANCC.

Case Managers
The Commission for Case Manager Certification has approved this program for a maximum of 1.00 clock hour(s) for Certified Case Managers (CCM).

AAPC-Certified Coders
AAPC will honor 1-for-1 CEUs for any live event offering CME credit or AMA PRA Category 1 Credit. A certificate of attendance or completion is necessary to show participation. The certificate will give the total CMEs possible for the offering. Physicians are advised to claim only the actual hours that they were present during the education. We ask that AAPC-certified members abide by this request also. One hour of instruction is worth one CEU.

Social Workers
R. Cassidy Seminars, ACE provider #1082 is approved as a provider for social work continuing education by the ASWB, through the ACE Program. Approval: April 15, 2015-April 15, 2018. R. Cassidy Seminars maintains responsibility for the program. Social workers should contact their board to determine course approval. Social workers will receive 1.00 continuing education (clinical) clock hours in participating in this course.

CA: Course meets the qualifications for (1.00) hours of continuing education credit for Marriage and Family Therapists, Social Workers, and Licensed Professional Counselors as required by the California Board of Behavioral Sciences, Provider #PCE418.

OH: Provider approved by the Ohio Counselor, Social Worker, and Marriage and Family Therapist Board for (1.00) clock hours, #RCST110701

A certificate of attendance will be provided to learners upon completion of activity requirements, enabling participants to register with licensing boards or associations that have not been pre-approved for credits. To apply for credit types not listed above, participants should use the procedure established by the specific organization to which you wish you apply credit.

Provided By
This activity is provided by OptumHealth Education.


Commercial Support
This activity is supported by Optum CarePlus.

Hardware/Software Requirements
To view this activity you will need Internet Explorer 7.0+ or Firefox 3.0+ with Windows Media Player 9+, RealPlayer 12+, or Adobe Flash Player 9+. Be sure to disable your pop-up blocking software prior to the beginning of this activity.

Target Audience

These materials are intended only for those that attended the live webcast on Thursday, June 25, 2015.

This activity is designed to meet the educational needs of physicians, nurses, case managers, social workers, chaplains, and other healthcare professionals who have an interest in transition of care.

Activity summary
Available credit: 
  • 1.00 AMA - Physicians
  • 1.00 ANCC - Nurses
  • 1.00 Attendance - General Attendance
  • 1.00 CCMC - General - Case Managers
  • 1.00 ASWB - Social Workers
Activity opens: 
Activity expires: 
Event starts: 
06/25/2015 - 1:00pm EDT
Event ends: 
06/25/2015 - 2:00pm EDT
United States

Available Credit

  • 1.00 AMA - Physicians
  • 1.00 ANCC - Nurses
  • 1.00 Attendance - General Attendance
  • 1.00 CCMC - General - Case Managers
  • 1.00 ASWB - Social Workers
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