creased by 34 percent, and adults over age 65 had the greatest increase in visit rate of all age groups (Roberts et al., 2008). In 2004 older adults made 15.7 million visits to EDs, which accounted for 14 percent of all ED visits. More than one-third of older adult ED patients arrived by ambulance, using ambulance transport at more than double the rate of ED patients as a whole (McCaig and Nawar, 2006). Despite older adults’ higher rates of using emergency services, many EDs are not prepared to address the unique needs of older patients (Hwang and Morrison, 2007; Wilber et al., 2006). These EDs do not have the expertise, equipment, or policies to provide optimal care for older patients.

Once they have been treated, older adults are more likely to have an overnight hospital stay and also more likely to have multiple overnight hospitalizations. In 2002 older adults accounted for more than 13 million inpatient discharges. The most common inpatient diagnoses included coronary atherosclerosis (hardening of the heart arteries and other heart disease), congestive heart failure, and pneumonia (Merrill and Elixhauser, 2005).

Forty-two percent of older adults receive some post-acute care services after discharge from the hospital. Approximately 27 percent of older adults are discharged to another institution, such as a skilled nursing facility (SNF) or rehabilitation center; another 15 percent receive home health care (AHRQ, 2007). Medicare covers up to 100 days (20 days of full coverage and 80 days of partial coverage) in a SNF after a hospitalization of at least three consecutive days (MedPAC, 2007b). The average length of SNF stays covered by Medicare in 2005 was 26 days (MedPAC, 2007a). Overall, almost 3 million Medicare beneficiaries received home health services in 2006, including skilled nursing, physical therapy, speech-language pathology services, aide service, and medical social work (MedPAC, 2007a). Medicare provides home health care to homebound beneficiaries needing part-time (fewer than 8 hours per day) or intermittent (temporary but not indefinite) skilled care to treat their illness or injury. Personal care and other non-skilled needs are not covered by Medicare.

Older adults are especially vulnerable as they transition between types of care. A lack of coordination among providers in different settings can lead to fragmentation of care, placing older adults at risk for absence or duplication of needed services, conflicting treatments, and increased stress (Parry et al., 2003). For example, medication changes, which are a common cause of adverse drug events, are not unusual in the transition from hospital to long-term care settings such as nursing homes and private home settings (Boockvar et al., 2004; Foust et al., 2005; Levenson and Saffel, 2007). Incomplete procedures during hospital discharge may also be linked to unnecessary rehospitalizations (Halasyamani et al., 2006; Kripalani et al., 2007). This type of fragmented care can also result from a lack of coordi-

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