Transition Management: A New Paradigm for Home Care of the Chronically Ill Near the End of LifePatients with advanced chronic illness receive increasingly fragmented care as they near the end of life. Multiple hospital readmissions are the rule, followed by intermittent episodes of home health care. Pain management, advance care planning, and preparation for dying may be lacking. Because prognosis is uncertain, particularly in noncancer cases, access to hospice and palliative care services is often denied to these patients until they are very near death. Home-based transition management can provide high-risk chronically ill patients better continuity of care until they are eligible and emotionally ready for hospice, and can manage their dying if referral to hospice is refused. Home care is positioned to provide innovative services that would increase access to end of life care. This paper outlines limitations of current approaches to end of life care, proposes potential components of transition management services, and discusses operational, regulatory, and reimbursement challenges to implementation.
Key Words: transition • death • chronic illness • cost effective • needs
Home Health Care Management & Practice, Vol. 15, No. 2,
126-135 (2003) This article has been cited by other articles:
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