Annual Review of Gerontology and Geriatrics, Volume 31, 2011

Peggye Dilworth-Anderson, PhD, is Professor of Health Policy and Management, Gillings School of Public Health at the University of North Carolina (UNC), Chapel Hill and Interim Co-director, UNC Institute on Aging. She is a past President of the Gerontological Society of America (2009-2010). Dr. Dilworth-Anderson is also an appointed member of the National Research Advisory Council for the NIH/NIA and the Medical and Scientific Advisory Council of the Alzheimer's Association. She has received numerous awards for her work; and in 2010, she was the recipient of the Ronald and Nancy Reagan Research Award for her research on Alzheimer's disease. She is a Fellow of the Gerontological Society of America and National Council on Family Relations. She currently serves on the Editorial Boards of Alzheimer's & Dementia, and Aging and Mental Health. Her publications span three decades. ||Mary H. Palmer, PhD, RNC, FAAN, is Professor and the Helen W. and Thomas L. Umphlet Distinguished Professor in Aging, at the University of North Carolina (UNC), Chapel Hill. She is an interim co-director of the UNC Institute on Aging and the project director of a Health Resources and Services Administration Comprehensive Geriatric Education Program grant entitled, ""Improving the Care of Acutely Ill Elders."" She is an Associate Editor of the Journal of the American Geriatrics Society and on the Editorial Boards of Geriatric Nursing and Clinical Geriatrics. Dr. Palmer is a Fellow in the American Academy of Nursing, American Geriatrics Society, and the Gerontological Society of America. She is the nurse representative to the International Continence Society's Ethics Committee and she serves on the Public Education Committee of the American Geriatrics Society. She is the author of award winning books on urinary continence and a widely published author of book chapters and professional journal articles.

FOREWORD




SECTION 1: SETTING THE STAGE ON TRANSITIONS OF CARE



1. Introduction Overview: A Contextual Conceptualization on Transitions of Care for Older Persons: Shaping the Direction of Care



2. Older Persons and Care Transitions



3. Family Involvement in Care Transitions of Older Adults: What Do We Know and Where Do We Go From Here?



SECTION 2: HEALTH ISSUES AND TRANSITIONS OF CARE



4. Physical Problems Shaping Transitions of Care




5. Complex Health Problems: Co-morbidities Shaping Transitions of Care




SECTION THREE: Legal, Ethical, and Decision-Making Issues on Transitions of Care



6. Planning and Decision-Making for Care Transitions



7. Advanced Directives and End-Life Decision Making



SECTION FOUR: Educating the Workforce for Transitions of Care



8. Educating Direct Care Workers on Transitions of Care



9. Educating the Interdisciplinary Team on Transitions of Care



SECTION FIVE: Charting the Future on Transitions of Care



10. Coming Full Circle: Planning for Future Pathways of Transitions of Care for Older Adults



11. Public Policy Implications for Pathways Through Transitions: The Rise of the Transitional Care Concept



12. Conclusion