Abstract
To address a gap in the transitional care (TC) literature, Project ACHIEVE established a multi-stakeholder workgroup to recommend essential components for the TC care of vulnerable older adults. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of TC components. Next, each TC component was compared with real-world patients’ and caregivers’ experiences. Ultimately, eight TC components were identified: patient engagement, caregiver engagement, complexity and medication management, patient education, caregiver education, patients’ and caregivers’ well-being, care continuity, and accountability. This session will define each component, describe the rationale for inclusion and describe how collectively, the eight components provide a framework for improving and evaluating high value TC.