Transitions in Care: Acute Care and the Older Adult

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Poorly planned or executed transitions of care may result in patients’ readmission to hospitals, poor clinical outcomes and inappropriate use of services. It is imperative that practitioners understand and utilize a multidisciplinary transition of care model to ensure continuity of health care as patients transfer between different locations or different levels of care.

Author Information

Susan Altfeld, PhD, MA (SW)
Clinical Assistant Professor
Community Health Sciences
Center for Research on Health and Aging
Associate Dean for Academic Affairs
School of Public Health
Co-Investigator, ENGAGE-IL
University of Illinois at Chicago

Author bio:
Dr. Susan Altfeld has been on the faculty of the University of Illinois at Chicago School of Public Health since 2005 where she is currently the Associate Dean for Academic Affairs. She received her master’s degree in social work from the University of Chicago School of Social Service Administration and a Ph.D. in Public Health from the University of Illinois at Chicago. Dr. Altfeld has worked in both health care and social work settings as a clinician, instructor, consultant and researcher. Her research interests include family caregiving throughout the life cycle, transitional care and evaluation of community-based interventions.

Michael Koronkowski, PharmD, CGP
Clinical Assistant Professor
Department of Pharmacy Practice
College of Pharmacy
Co-Investigator, ENGAGE-IL
University of Illinois at Chicago

Co-Author bio:
Dr. Michael J. Koronkowski received his B.S. in Pharmacy in 1986 from Drake University College of Pharmacy and Health Sciences. His Pharm.D. degree was conferred in 1990 from Purdue University College of Pharmacy and Pharmacal Sciences. He completed a Pharmacy Practice Residency program at the Philadelphia College of Pharmacy in 1992 and a Fellowship in Geriatrics at the University of North Carolina at Chapel Hill in conjunction with Duke University and Glaxo Research Institute in 1994.

Dr. Koronkowski joined the faculty at the University of Illinois at Chicago in 1994 as a Clinical Assistant Professor in the Department of Pharmacy Practice. Currently, he practices in Internal Medicine/Geriatrics as a Clinical Pharmacy Practitioner at the University of Illinois Hospital and Health System. His research interest include: geriatric pharmacotherapy management, adverse drug reactions, medication safety, post-acute care transitions, and evidence-based interdisciplinary practice models. Current research program funding is ongoing through the Illinois Department on Aging (IDoA), Chicago Department of Family Support Services, Senior Services, White Crane Wellness Center, Age Options-Area Agency on Aging targeting community-based senior wellness and the Department of Health and Human Services, Health Related Services Administration (DHHS-HRSA) Geriatric Workforce Enhancement Programs entitled ENGAGE-IL and CATCH-ON targeting Older Adults with Multiple Chronic Conditions in Primary Care.

Valerie Gruss PhD, APN, CNP-BC
Associate Professor
College of Nursing
Director, ENGAGE-IL
University of Illinois at Chicago

Memoona Hasnain MD, MHPE, PhD
Professor and Associate Department Head, Faculty Development & Research
College of Medicine,
Department of Family Medicine
Co-Director, ENGAGE-IL
University of Illinois at Chicago

Module Information

Duration: 30 minutes
Format: Video Stream & pdfs

Module Guide and Handout
Resources & References
Continuing Education Credit Information

In support of patient care, Rush University Medical Center is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for the healthcare team.

Rush University Medical Center designates this live activity for a maximum of (0.50) AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

This activity is being presented without bias and without commercial support.

ANCC Credit Designation – Nurses
The maximum number of hours awarded for this CE activity is 0.50 contact hours.

Rush University is an approved provider for physical therapy (216.000272), occupational therapy, respiratory therapy, social work (159.001203), nutrition, speech-audiology, and psychology by the Illinois Department of Professional Regulation. Rush University designates this live activity for (0.50) Continuing Education credit(s).

Rush University Medical Center designates this knowledge based CPE activity for 0.50 contact hours for pharmacists.

Learning Objectives

Upon completion of this module, learners will be able to:

Define transitional care
Discuss post-acute care discharge destinations
Identify risk factors for adverse outcomes from acute care, with special focus on older adults
Summarize effective strategies to facilitate safe transitions from acute care for older adults
Discuss the role and value of interprofessional support for older adults to ensure a successful transition from acute care

Technical Support / Contact Info

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This ENGAGE-IL learning activity fully complies with the legal requirements of the ADA and the rules and regulations thereof. Learners with special needs can make requests for accommodation at any time by sending e-mail to

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