The impact of home care on transitional care is imperative to understand as our healthcare system undergoes scrutiny. We are all looking for ways to deliver more cost-effective care, particularly for the older population for whom care is most costly. When planning care for this population with multiple, complex health problems and geriatric syndromes, especially in combination with age-related changes, as well as psychological, social, and environmental changes, preventing fragmentation of care and breakdown in communication are serious challenges. Although Medicare (A), as an entitlement, provides basic healthcare (hospital, hospice, and home care) coverage for most adults age 65 and older, healthcare is extremely expensive, primarily due to breakdowns within the system and specifically in handling transitions. What are the basic factors within our healthcare system that contribute to patients "falling through the cracks"-especially for the more challenging, complex older patients?

Frequently, older adults move from environment to environment with the healthcare system; however, communication between healthcare providers, patients, and caregivers is often poor. Transfers are often inadequate, lacking necessary follow-up services and a single coordinated plan. Coordination of care is a key foundational building block of healthcare; it is essential to patient-centered care and a priority outcome designated by the Institute of Medicine (2001), which is necessary for attaining quality healthcare goals. Transitions of care are defined as "a set of actions designed to assure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care in the same locations" (Coleman & Berenson, 2004).

Quality is assumed to be the result of "...providing the right care in the right way at the right time," but a patient-centered vision of quality would mean "...providing the care that the patient needs in the manner the patient desires at the time the patient desires" (Davis et al., 2005, p. 953). So it is important that patient goals and provider goals be aligned. That certainly could be considered the first step, but what are the essential components in assuring quality, transitional care? Some of the underlying principles of transitional care include the following: patient-centered care approaches, early assessment of discharge needs, enhanced patient and caregiver education, timely and complete information and communication between providers at the time of transfer, early post-acute follow-up, attention to health literacy/cognitive status/culture, effective medication management, assessment of psychosocial and environmental indicators, and collaboration with all the members of the interdisciplinary team.

Ideally, an older adult would receive patient-centered care during an acute hospitalization and return home in an improved, stable state of health. However, that is often not the case; home care is often essential, providing rehabilitation and short-term follow-up care for older adults who require short-term services to enhance independent functioning. The articles in this edition of Home Healthcare Nurse are particularly relevant to the subject of transitional care, focusing on factors that impact the successful transition from hospital to home and are important to nursing care delivery. First, social support is a fundamental component of successful transitional care to the home, as discussed by Larry Hill in From a Caregiver's Heart. Also, Silver, Ferry, and Edmonds discuss clinical process design, management practices, organizational factors, and the interaction between diverse elements of a complex healthcare system as these factors relate to the causes of unplanned hospital admissions among home care patients. Mullin discusses the need to strengthen the culture of safety and implement safety standards while improving communication processes in home care. Although depression among older adult home care population has often gone undetected and untreated, Sheeran, Reilly, Weinberger, Bruce, and Pomerantz discuss the need for identifying and effectively treating older adults in home care. Depression can lead to compromised self-management of health conditions and poor health outcomes, complicating the transition from hospital to home. These authors recommend and provide guidelines for using the PHQ-2 on the Outcome and Assessment Information Set-C to screen for depression. One major source of problems in transitional care, particularly from hospital to home, is nurse-physician communication. Kogan, Underwood, Desmond, Hayes, and Lucien discuss factors impacting physician communication in managing community-dwelling older adults. Implementing multidisciplinary plans of care necessitates nurse-physician communication-an area of difficulty in home care. These authors recommend best practices for nurses in communicating with physicians.

The goal of transitional care is the delivery of patient-centered coordinated care, including the coordination of social and long-term-care services along with medical management. The home care nurse must guide an interdisciplinary healthcare team who can work together collaboratively with the focus on the patient and caregiver. The articles in this edition of the journal will help to prepare nurses to critically analyze both the strengths and limitations of current approaches used in caring for the older population and prepare you, as nurses, to implement evidence-based changes for our healthcare delivery.

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