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Care Transitions, Patient Health, and System Performance in the United States  

June Simmons, Sandy Atkins, Janice Lynch Schuster, and Melissa Jones

Transitions in care occur when a patient moves from an institutional setting, such as a hospital or nursing home, to home or community, often with the hope or expectation of improving health status. At the very least, patients, clinicians, and caregivers aim to achieve stability and avoid complications that would precipitate a return to the emergency department (ED) or hospital. For some groups of vulnerable people, especially the very old and frail, such transitions often require specific, targeted coaching and supports that enable them to make the change successfully. Too often, as research indicates, these transitions are poorly executed and trigger a cycle of hospital readmissions and worsening health, even death. In recognizing these perils, organizations have begun to see that by improving the care transition process, they can improve health outcomes and reduce costs while ensuring safety, consistency, and continuity. While some of this improvement relies on medical care, coaching, social services and supports are often also essential. Lack of timely medical follow-up, transportation, inadequate nutrition, medication issues, low health literacy, and poverty present barriers to optimal health outcomes. By addressing social and environmental determinants of health and chronic disease self-management, social workers who make home visits or other proven timely interventions to assess and coach patients and their caregivers are demonstrating real results. This article describes care transitions interventions, research into barriers and opportunities, and specific programs aimed at improvement.

Article

Transitions of Youth in Foster Care  

Joe M. Schriver

This entry focuses on the transition to independent living process required of youth and young adults who are “aging out” of the foster care system. It addresses the multiple risks and challenges faced by young people who are aging out of care and those of young adults who have “aged out.” This entry addresses existing policies and programs intended to assist youth who are transitioning from care. Current research findings about the experience of these youth over time both prior to and after exiting foster care are presented. Finally, the unique risks and challenges faced by as well as existing resources for LGBTQ youth who are in the process of or who have aged out are presented as an exemplar of unique needs and experiences of youth from vulnerable populations. Attention is also given to the strengths and resiliency of many former foster care youth who successfully make the transition from foster care to independent living.

Article

Child Welfare: Overview  

John Paul Horn, Emily Bruce, and Toni Naccarato

In the United States, the child welfare system is composed of multiple services to keep children safe, either by strengthening family units, preventing maltreatment, or providing alternative care arrangements for children who are unable to safely remain at home. These services include child protection, family support and maintenance programs, reunification, and out-of-home care. Some children return safely to their families, but other children might never return home. Services for these youth might include adoption, guardianship, and/or transitional planning for youth exiting foster care to adulthood. Case-carrying social workers hold responsibility for assessing the case, making recommendations to the court, and preparing reports for parents, court officers, and sometimes for dependent children (based on their age). These individuals are professional social workers with graduate degrees in social work. Case aids or case assistants often provide support services for the case-carrying social worker.