CARE TRANSITIONS PROGRAM FOR SURGICAL PATIENTS WITH OLDER AGE, COGNITIVE DECLINE AND/OR FRAILTY - Research report - outcomes and implementation

Sep 28, 2026

Uploaded by nayy☆

CARE TRANSITIONS PROGRAM FOR SURGICAL PATIENTS WITH OLDER AGE, COGNITIVE DECLINE AND/OR FRAILTY adapts the C‑TraC coordinated transitional care protocol for surgical patients with frailty, older age, and/or cognitive impairment. A nurse case manager worked with a geriatrician and surgery teams to deliver pre‑discharge visits and weekly post‑discharge telehealth for up to four weeks, reinforcing discharge education, follow‑ups, medication adherence, functional supports, and contact access. After piloting in 2023, 51 patients entered revised 2024 implementation, with readmission rates reported for partial and full program completion.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Program overview

Intervention components and workflow

Patient population and implementation

Readmission outcomes and feedback

1220 Innovation in Aging, 2025, Vol. 9, No. S2 Abstract citation ID: igaf122.4083 CARE TRANSITIONS PROGRAM FOR SURGICAL PATIENTS WITH OLDER AGE, COGNITIVE DECLINE AND/OR FRAILTY Marianne Desir1, Lisa Hue2, Sofia Economidou3, and Naixin Kang4, 1. Veterans Health Administration, Miami, Florida, United States, 2. Hackensack Meridian Health, North Bergen, New Jersey, United States, 3. University of Miami/ Jackson Health System Fellowship in Geriatric Medicine, Miami, Florida, United States, 4. Miami Veterans Affairs Healthcare System, Miami, Florida, United States C-TraC (Coordinated Transitional Care) is a protocol-driven hospital care transition program that has been offered primarily to patients admitted to medical wards. We adapted C-TraC with a target population of surgical patients with frailty, older age and/or cognitive impairment. A nurse case manager collaborated with a geriatrician and the surgery service to provide pre-discharge visits and weekly post-discharge telehealth visits for up to four weeks. In these visits the nurse: 1) reinforced discharge education; 2) ensured awareness of follow-up appointments; 3) discussed Innovation in Aging, 2025, Vol. 9, No. S2 1221 home medications and medication adherence; 4) ensured availability of sufficient functional supports; and 5) ensured awareness of contacts for future questions. After initial piloting in 2023, 51 patients participated in the program during the revised implementation in 2024. Average age was 75 years. Most common surgery types were orthopedic (n = 13), general surgery/ surgical oncology (n = 9), vascular (n = 6) and urology (n = 5) . 30 patients completed the full C-TraC program. Among historical controls, the readmission rate was 13.3%. Among the 51 patients completing at least the C-TraC visit at hospital discharge, readmission rate was 9.8%. Among the 30 patients who completed the full C-TraC program, the readmission rate was 10.0% . The 30 patients who completed the full program were reached by phone for program evaluation; all described that the program was either moderately or very much a positive aspect of their experience with VA healthcare. Our experience supports that C-TraC can be successfully adapted and implemented for the target population of surgical patients with frailty, older age and/ or cognitive impairment.

FAQs

What problem does the CARE TRANSITIONS PROGRAM target?

It targets care transitions for surgical patients with older age, cognitive decline, and/or frailty, adapting C‑TraC to better support this population during hospital discharge and early recovery.

What care activities are delivered in the program?

A nurse case manager provides pre-discharge visits and weekly post-discharge telehealth for up to four weeks, reinforcing discharge education, follow-up awareness, medication adherence, functional support availability, and future contact resources.

How many patients participated and what readmission results were reported?

In revised 2024 implementation, 51 patients participated; 30 completed the full program. Readmission rates were reported as 13.3% for historical controls, 9.8% for patients with at least the discharge visit, and 10.0% for those completing the full program.

Sep 28, 2026

Uploaded by nayy☆