GHA 548 Week 4 Aging Across the Continuum of Care Example

Seven Settings in Nine Weeks: Following an 84-Year-Old Through the Continuum of Care After a Hip Fracture and What Each Handoff Taught a Health System

[Student Name]

University of Phoenix

GHA/548: Foundations of Gerontology for Health Administrators

Week 4 Assignment

[Instructor Name]

[Date]

The patient, her husband and the health system are composites written for a model paper; Medicare rules, payment amounts and research findings come from the sources listed.

At 5 a.m. on a Tuesday, an 84-year-old retired bookkeeper fell in her kitchen. Her husband of 60 years, who has mild dementia, found her on the floor and called their daughter, who lives 40 minutes away, rather than 911. The daughter called for an ambulance. Over the next nine weeks, the patient received care in seven settings of a composite regional health system. This paper follows her path, explains how each setting is paid for and identifies what each handoff taught the system.

Setting One: The Emergency Department

An X-ray showed a hip fracture. The emergency physician took a history from the daughter by phone, because the patient was in pain and the husband could not give details. No one asked who would care for the husband.

Setting Two: Surgery and the Hospital Stay

She had surgery the next morning and stayed four midnights as an inpatient, meeting Medicare's qualifying stay for later nursing facility coverage. Her Medicare Part A deductible for the stay was $1,736 in 2026, paid by her supplemental policy (Centers for Medicare & Medicaid Services, 2025). On the second night she no longer knew where she was, tugged at her IV and received a sedative from the night team. Delirium is common in hospitalized older adults and often preventable. In a controlled trial, a program addressing orientation, sleep, early mobility, hydration and vision and hearing aids reduced delirium from 15.0% to 9.9% (Inouye et al., 1999). The hospital had no such program on the orthopedic unit.

Setting Three: The Skilled Nursing Facility

From the hospital she went to a nursing facility for short-term rehabilitation. Medicare covers such stays after a qualifying inpatient stay, with no coinsurance for the first 20 days and a daily coinsurance of $217 for days 21 to 100 in 2026 (Centers for Medicare & Medicaid Services, 2025). She stayed 18 days. The facility received a discharge summary but an outdated medication list that included a blood pressure medicine the hospital had stopped.

The Husband at Home

While she was away, the daughter took leave from work to stay with her father, whose confusion worsened without his wife's routines. No one in the health system had asked about him. The daughter later called him the patient no one saw.

Setting Four: Home Health

Back home, she received Medicare home health services: a nurse twice a week and physical therapy three times a week. On the first nurse visit, the nurse found two bottles of the same blood pressure medicine, one restarted from the old list. Her blood pressure was low, and she was dizzy. The nurse contacted the physician, and the duplicate was stopped. A medication list is only as accurate as the last handoff that copied it.

Setting Five: Outpatient Therapy

After four weeks of home health, she moved to outpatient physical therapy. She needed rides, which her daughter provided on weekends only, so she missed three of the first eight sessions.

Setting Six: Primary Care

Her first primary care visit after discharge came 26 days after she left the nursing facility, because the earliest appointment was that far out. Her physician had not received the nursing facility's discharge summary.

Setting Seven: Community Services

A social worker at the primary care clinic referred the couple to the Area Agency on Aging, which arranged a volunteer driver for therapy, adult day services for the husband two days a week and caregiver support for the daughter.

Why Each Setting Worked Alone

The fragmentation had a financial logic. Medicare paid the hospital a fixed amount for the surgical stay, the nursing facility a daily rate adjusted for her needs, the home health agency for each 30-day period of care and the physicians for each service. No payment rewarded the hospital for her outcome after discharge or the nursing facility for checking the hospital's medication list. Each setting did its own job reasonably well, and no one was paid to own the whole path. Accountable care arrangements and bundled payments try to change this by making one organization responsible for cost and quality across settings, and the system's growing share of patients in such contracts gives it a business reason to act.

The Daughter's Nine Weeks

The daughter, a 56-year-old accountant, became the only person who saw the whole path. She relayed the medication list between settings, arranged her father's care, drove to therapy on weekends and used 11 days of vacation and unpaid leave. She kept a notebook of every name, phone number and instruction because no single contact existed. By week six she was sleeping poorly and had missed a deadline at work. Her experience is typical of family caregivers, and it shows that any redesign of transitions must include the caregiver as a member of the team, with a named contact and a copy of every plan.

What the Handoffs Taught

Four patterns stand out. Information was lost or outdated at every handoff. The family caregiver, the daughter, coordinated most of the care without being part of any team. The husband's needs were invisible to a system organized around individual patients. And services that would have helped, such as delirium prevention and community support, came late or not at all.

Evidence on Transitions

Research shows transitions can be improved. In a trial of older adults at high risk, an advanced practice nurse who planned discharge and visited patients at home left 20.3% of patients readmitted within 24 weeks, against 37.1% under usual care, and cut Medicare spending roughly in half (Naylor et al., 1999). In another trial, a transition coach who taught patients to manage medications and follow-up reduced 30-day readmissions from 11.9% to 8.3% (Coleman et al., 2006).

Five Changes for the System

The director proposed five changes. First, a delirium prevention program on the orthopedic and medical units, with volunteers supporting orientation and mobility. Second, a single reconciled medication list sent at every discharge and verified by pharmacists for patients 65 and older. Third, a question at every admission of an older adult: does anyone depend on you for care? Fourth, a transitional care nurse for high-risk older patients discharged to home or post-acute care, with a follow-up appointment within seven days. Fifth, a formal referral pathway to the Area Agency on Aging.

Measuring the Changes

The system will track delirium rates, medication discrepancies found at the first home health visit, days to first primary care visit and 30-day readmissions for patients 65 and older, reporting quarterly.

Conclusion

In nine weeks, an 84-year-old passed through seven settings, each paid differently and each working largely alone. Delirium, a medication error, a late follow-up and an unseen husband were the costs of fragmentation. Evidence from delirium prevention and transitional care trials shows these gaps can be closed, and the system's five changes aim to close them for the next patient.

References

Centers for Medicare & Medicaid Services. (2025). Medicare program; CY 2026 inpatient hospital deductible and hospital and extended care services coinsurance amounts. Federal Register, 90, 52075. https://www.federalregister.gov/d/2025-20249

Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. https://doi.org/10.1001/archinte.166.17.1822

Inouye, S. K., Bogardus, S. T., Jr., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., & Cooney, L. M., Jr. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine, 340(9), 669-676. https://doi.org/10.1056/NEJM199903043400901

Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA, 281(7), 613-620. https://doi.org/10.1001/jama.281.7.613