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Am Fam Physician. 2022;106(5):567-570

This is part 1 of a two-part Curbside Consultation on care transition for older adults. See part 2, The Physician's Role in Transitioning Older Adults Into Long-term Care Facilities.

Author disclosure: No relevant financial relationships.

Case Scenario

My 83-year-old patient, E.P., with a history of Alzheimer disease, hypertension, hypothyroidism, and mild chronic obstructive pulmonary disease, has received care from a home health aide and family support in the home for two years. Although their comorbidities are stable, E.P. is now falling frequently, is experiencing delusions and hallucinations, has bowel and bladder incontinence, and is unable to dress and bathe properly. E.P. is no longer able to direct medical and executive affairs; however, their daughter (E.P.’s power of attorney) would like to look at options other than a long-term care facility and has asked for assistance in finding care alternatives for her parent. Financial resources are running out.

What are alternatives to long-term care facility placement? What are the critical issues I need to understand and what actions should I take to assist the patient and family in finding the most appropriate alternatives?


The goal of care transitions for older adults is to promote the best possible safe functioning for the individual in the least restrictive environment throughout their late life. Some needs of older adults for assistance due to normal aging, medical comorbidities, or disablement may be anticipated if the physician and caretakers attend to the changing medical, psychosocial, and goals of care needs of the patient.


Common reasons for care transitions are listed in Table 1. The functional and behavioral problems of dementia are particularly taxing for patients and caregivers, and they often require care transitions to other environments.

Patient factors
 Decline in function (e.g., activities of daily living and instrumental activities of daily living such as mobility, self-care, communication)
 New, acute medical condition (e.g., injury, infection)
 Progression or exacerbation of chronic medical conditions resulting in need for external support (e.g., medication management, transportation, intravenous antibiotics, management of Foley catheter, wound care)
 Worsening cognitive impairment, dementia-related behavioral and psychological symptoms (e.g., aggression, agitation, delusions, hallucinations)
Family, caregiver, social, or environmental factors
 Caregiver burden or fatigue when family or caregiver cannot meet patient needs (e.g., medical, emotional, social)
 Environmental factors such as inadequate or unsafe housing, changes in transportation or community resources (e.g., pharmacy, grocery store)
 Financial limitations
 Loss of spouse or support group, social isolation, unbefriended older adult
 Physical distance between family and patient
 Time requirements
Transition from hospitalization
 Adapting to a new normal after hospitalization, surgery, or injury
 Education and management of new or progressing medical conditions
 Medication monitoring, adjustment, and adherence
 Need for therapy to improve or maintain function and independence
End-of-life care
 Hospice criteria are met*
 Respite services for caregivers


Current or potential caregiver responsibilities and fatigue are essential considerations in patient transitions of care, especially if caregivers are themselves older adults or in poor health. Caregiver responsibilities can lead to adverse physical, emotional, financial, and functional outcomes for both the patient and caregiver and increased use of health and other supportive services. Caregiver fatigue and duties are powerful predictors of patient institutionalization and termination of home care.1 Caregivers should be screened for increasing burden, and their status must be considered when deciding on appropriate transitions of care.2 Early caregiver assessment and education, promotion of respite care, and discussions about advance care planning are critical responsibilities of the physician.3


Ideally, planning for provision of practical assistance in the home occurs years before a medical or social crisis. Aging in place is a concept that encourages older adults to create practical plans to meet future housing, financial, transportation, recreational, and health and wellness needs.4 Financial planning may include estate planning for those with substantial assets who can afford this service. Financial planning may also include consideration of long-term care insurance to facilitate more in-home care options than those covered by Medicare, such as nonskilled care or environmental modifications in the home.5

The resources available for older adult care are unique to each patient and community. Physician understanding of these resources within their community is important for answering questions about care options for older adults. Area Agencies on Aging can provide vital assistance and are accessible in all areas of the country.6 Consultation with a social worker can be invaluable in assisting the physician, patient, and family in choosing the most appropriate strategies for care.


Table 2 presents transition of care options.714 The choice of setting is a dynamic interplay of factors, including needs, goals of care, patient preferences and capacity for directing their own affairs, caregiving support, and family and community resources. The continuum of care ranges from services in the home with aides, adult day centers, Programs of All-Inclusive Care for the Elderly (PACE), and facility-based care (ranging from group homes to long-term care facilities). Patient qualifications, scope of services, physician participation, and cost vary among the venues of care.

OptionsQualifying criteriaExclusionsServices providedResponsible physicianCost*PayerMiscellaneous
State-supported Medicaid home waiver programsVaries; typically qualifies for Medicaid long-term care serviceVaries; needing 24/7 care or does not have a homeVaries; home health aide up to 20 hours per week; hospicePrimary care physicianVaries; median pay for home health aide (2021), $14.15 per hour8 MedicaidNA
Home aideAnyNAVariesPrimary care physicianMedian pay, $14.15 per hour8 PrivateNA
Adult day centerVaries; may have two or more activities of daily living deficitsNeeding 24/7 care or does not have a homeVaries with scope of service; activities of daily living; available one to five days per week; medication management; transportation; recreationPrimary care physicianMedian cost, $78 per day9 Medicaid or privateAdditional services may incur additional cost
PACETwo or more activities of daily living deficits; qualifies for long-term care facility but has home resources; usually 65 years or olderNeeding 24/7 care or does not have a homeAdult day center services one to five days per week
Some home health aide services; medical care; rehabilitation; life-line availability; transportation; medication management
PACE providerNo premium for Medicaid-eligible patients10 Dual (Medicaid/Medicare)On-site primary care, therapy (occupational, physical), podiatry and dental services; program contracts with hospitals, subspecialty care, skilled nursing/long-term care facilities
Group homeYounger adults: mental health or intellectual impairment
Older adults: frailty
Wandering; staff cannot give medications as needed unless patient communicates needMonthly vitals; certified nursing assistant–level support; no on-site nursingPrimary care physicianVaries widely11 Private or MedicaidNA
Independent living facilityIndependentHaving dementiaVaries for nursing care, meals, and monitoringPrimary care physicianVaries widely12 PrivateMay drive, work
May use private resources for care or pay for additional services
Assisted living facilityVaries: often instrumental activities of daily living deficitsVaries; wandering; behaviors and continence care may be limitingVaries for nursing care, meals, and monitoringVaries, usually primary care physicianMedian, $4,300 per month13 Private; long-term care insuranceMedical care is responsibility of patient or family
Impairment in activities of daily living and instrumental activities of daily living common
Long-term careTwo or more activities of daily living deficitsBehaviors, unless a separate dementia care unit is available24/7 nursing care; monthly vital signsVaries (primary care physician vs. long-term care practice group)Median, $7,756 per month for semi-private14 Medicaid; long-term care insurance; privateFacility is responsible for coordinating medical care


For patients with private insurance, long-term care insurance, and/or financial resources, continuing care retirement communities may be an option. Additionally, assisted living facilities and memory support units may be available to support patients who do not require long-term care services.

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Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at

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