The Role of the Geriatric Specialist in Care Transitions
Presented by Jason R. Falvey
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Rehabilitation professionals have an important role in helping older adults transition from hospitals to the community. This course will evaluate contemporary evidence linking impairments in physical function with hospital readmissions and provide actionable strategies rehabilitation professionals can employ to address these factors within medically vulnerable older adult populations. This course will also evaluate how social and environmental contextual factors influence rehabilitation outcomes for older adults and how geriatric rehabilitation specialists can help patients overcome these barriers. Overall, this course will provide a roadmap for examination, evaluation, and management of older adults transitioning through the posthospital continuum of care—all critical skills for the geriatric specialist.
Meet your instructor
Jason R. Falvey
Jason Falvey is a postdoctoral fellow at Yale University. His research training focuses on disability and recovery for older adults after acute hospitalization and how physical function contributes to hospital readmission risk. He received his PhD in rehabilitation science from the University of Colorado, Anschutz Medical…
Chapters & learning objectives
1. Physical Function and Hospital Readmissions
This chapter will evaluate current evidence linking impaired physical function and hospital readmissions, in the context of current payment policy. We will review how the timing and trajectories of disability and recovery surrounding hospitalization impact readmission risk and how this informs timing of treatment interventions.
2. Contemporary Trends in and Evidence for Rehabilitation Involvement in Care Transitions
This chapter will evaluate how rehabilitation professionals are currently involved in management of patients transitioning between the hospital and community, and the evidence supporting this involvement. We will identify potential gaps in care and discuss how filling these gaps may promote improved readmission outcomes.
3. Contextual Factors During Care Transitions: The Role of the Geriatric Specialist
This chapter will review how home- and community-based contextual factors, such as housing quality, poverty, and neighborhood factors, may influence care transitions. We will evaluate how geriatric specialists can help patients overcome these barriers while practicing at the top of their scope of practice.