• care transitions;
  • interdisciplinary care;
  • pilot study


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  2. Abstract

Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri-FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri-FITT, a geriatrician–geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self-management, communicates with primary care providers, and follows up with patients soon after discharge.

This pilot cohort study of Geri-FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri-FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri-FITT on patients' care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri-FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care.

Geri-FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.

Hospitalization and transition to postdischarge sites of care can be dangerous for older adults, often leading to functional decline and medical complications such as delirium, adverse drug reactions, pressure ulcers, bowel and bladder dysfunction, malnutrition, and dehydration.1,2 Transfers within the hospital or to other sites of care are especially hazardous,3 often occurring without input from patients or caregivers with important knowledge of patients' personal values, needs, and goals. During transitions, older patients encounter many healthcare providers without specialized training in geriatrics. Lack of coordination and effective communication between providers, patients, and caregivers during transitions results in low patient satisfaction. Effects extend into the postacute and ambulatory care setting, resulting in adverse events, early readmissions, and higher healthcare costs.4–6


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Innovations in healthcare services have improved care for older patients in hospitals and during their transitions to postacute settings by creating specialized hospital units for older adults at high risk for adverse outcomes,7–9 providing inpatient geriatric consultation,10–17 or optimizing transitional care for select populations.18–23 The most significant improvements in healthcare outcomes for hospitalized older adults have been associated with intensive inpatient geriatric units (e.g., Geriatric Evaluation and Management and Acute Care for Elders units) or programs targeting specific geriatric syndromes, but intensive inpatient units are not suitable for every hospital given capital costs and logistical challenges, and patients not on these units do not typically receive geriatric evaluation (i.e., functional and cognitive assessment). Inpatient geriatric consultation has produced mixed results, including reduction in 6-month mortality24 and improvement in mental status,17 but no improvement in physical function.10 A recent systematic review demonstrated the value of good transitional care for hospitalized older adults and suggested that care coordination is most likely to produce savings for insurers.25

The authors developed a new model, termed the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), with a goal of improving acute and postacute care by combining aspects of geriatric evaluation and transitional care models into a comprehensive acute and postacute comanagement model. The Geri-FITT design is unique, because the same healthcare professional team provides inpatient and transitional care, allowing for stronger patient–provider relationships and more-efficient communication with care plan implementation. Stronger relationships can result in better adherence, patient satisfaction, and health status.26,27 Efficient postdischarge communication is related to fewer medical errors and adverse drug events and lower readmission rates.5,28–30 The Geri-FITT model provides geriatrics expertise and services not provided consistently by inpatient professionals to older patients and is designed for implementation in academic and community hospitals.


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  2. Abstract

Development and Operation of the Geri-FITT Model

Combining lessons from previous research with survey results of medical and nursing experts, the investigators designed a comprehensive acute and postacute comanagement model of care with three goals for older adults with acute illnesses: improve quality of inpatient care; improve safety and efficiency of care transitions; and improve geriatric knowledge, skills, and attitudes of inpatient physicians and nurses.

The Geri-FITT model includes a geriatric nurse practitioner (GNP) and a geriatrician who evaluate older medical inpatients, comanage geriatric syndromes with inpatient physicians and nursing staff, prepare patients and caregivers for care transitions by clarifying patient-specific goals and teaching self-management skills, and assist the inpatient medical–nursing team and other healthcare professionals in developing and executing transitional care plans. After discharge, the Geri-FITT team follows up with the patient and communicates with the primary care physician to ensure continuity of care. The team also educates inpatient medical–nursing teams in the use of geriatric care principles and best practices (details of educational intervention published elsewhere).31

In this pilot study, the team was composed of one GNP and a group of rotating clinician–educator geriatricians who provided Geri-FITT services to all consenting patients aged 70 and older admitted to two general medicine services of a university teaching hospital during 2007. For patients who lacked decision-making capacity, the option to participate was offered to primary informal caregivers.

The team elicited patients' goals of care and assessed their cognitive function,32,33 risk of falling, functional status,34 mood,35 medications,36 and relevant geriatric syndromes (e.g., sleep disturbance, delirium, constipation, incontinence, and falls).37 The team then provided written management recommendations to the inpatient medical–nursing team and met with them nearly every day to comanage geriatric syndromes. The GNP also discussed the patients' health-related beliefs, preferences, and informational needs with other involved rehabilitation therapists, case managers, social workers, and house staff.

Throughout the Geri-FITT patients' hospital care, the GNP monitored their progress; discussed their care with inpatient physicians, nurses, social workers, and rehabilitation therapists; provided patient and caregiver education about medications and self-management skills; and prepared patients and caregivers for expectations at the next site of care. The GNP also provided ongoing nursing staff education focused on identification and management of geriatric syndromes.

Within 48 hours of each patient's discharge, the GNP, in consultation with the inpatient team, prepared a letter to be faxed to the PCP, providing a brief description of the hospitalization, medication changes, and geriatric-specific recommendations. Within 2 days of discharge, the GNP also telephoned the patient or caregiver to review symptoms, medication use, self-management skills, and follow-up instructions. The following provides a brief summary of the intervention:

  • Hospital Day 1 or 2
  • GNP-led geriatric assessment of patient, elicitation of patient preferences
  • Care plan discussion with geriatrician
  • Documentation of recommendations in medical record
  • Verbal discussion of comanagement recommendations to patient or caregiver and medical staff
  • Hospital Days 2 and on
  • Monitoring of patient progress and plan of care
  • Comanagement with medical team of geriatric syndromes
  • Medical and nursing staff education about geriatric principles
  • Patient discharge needs assessment with case manager and rehabilitation therapists
  • Patient or caregiver education, preparation for next site of care
  • Day 1 or 2 after discharge
  • Telephone call to patient or caregiver to assist with medication reconciliation and medical concerns
  • One-page summary of hospitalization and care plan faxed to PCP

The Geri-FITT team evaluated approximately five new patients and made approximately eight follow-up patient visits each week. The GNP spent an average of 30 hours per week performing clinical duties (19–20 h/wk), teaching (2–3 h/wk), and administrative work (8–9 h/wk). Of the 19 to 20 clinical hours per week, approximately 13 hours were devoted to direct patient care, 4 to 5 hours to postdischarge follow-up, 1 to 2 hours to interdisciplinary team communication, and 0.5 hours to communication with patients' families. Four hours were spent on average per patient. The geriatricians spent 9 to 10 hours per week, including clinical duties (5–6 hours), teaching (1–2 hours), and administrative work (2–3 hours).

Study Design and Setting

To assess the Geri-FITT model's effects on inpatient and transitional care, the investigators conducted a 1-year pilot study of older adults admitted to four similar general medicine teaching services (which encompass six nursing and medical units) at an academic medical center between January 1, 2007, and December 15, 2007. Two of the four services were randomly selected to test the Geri-FITT model, and the other two services continued to provide usual inpatient care. The institutional review board of the Johns Hopkins School of Medicine approved this study (Protocol NA__00003703).


Patients were offered participation in the study if they were aged 70 and older. Because Geri-FITT did not provide care on weekends, patients who were admitted or discharged on a weekend were excluded. Non-English-speaking patients who lacked an English-speaking caregiver were also excluded. Of the 1,618 patients admitted to the units offering Geri-FITT services, 366 (22.6%) were eligible for the study, 265 (72.4%) of these were offered participation, and 244 (92.1%) of those offered participation consented to be in the study (Figure 1). Of the 1,664 patients admitted to the units that served as controls, 351 (21.1%) were eligible for the study, 242 (68.9%) of these were offered participation, and 216 (89.3%) of those offered participation consented to be in the study. Of the patients who consented, 61.9% in the Geri-FITT group and 54.6% of those in the control group completed the 14-day follow-up interview.


Figure 1.  Participant flow from January to December 2007.

Download figure to PowerPoint


Fourteen days after each patient's discharge from the hospital, a research assistant, blinded to group assignments, telephoned the patient to administer a brief survey. The survey included the three-item Care Transitions Measure (CTM-3)38 and four questions about satisfaction with inpatient care. The CTM-3 is found to correlate well with the CTM-15 (coefficient of determination=0.88),39 which demonstrates high internal consistency (Cronbach alpha=0.93), reliability, and applicability for assessment across healthcare settings.40 The CTM-3 was chosen for this pilot study, because it imposes less respondent burden than the CTM-15, low scores are significantly associated with hospital utilization (∼35% vs 15%), and the National Quality Forum has endorsed it to be used for the public reporting of the quality of care transitions.40 The CTM-3 consists of three statements (“When I left the hospital, I clearly understood the purpose for taking each of my medications.”“The hospital staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left the hospital.”“When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.”) Respondents indicated their extent of agreement on a Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree).

Patients also responded on a 5-point Likert scale, ranging from very dissatisfied to very satisfied, to indicate their degree of satisfaction with their overall inpatient care, their inpatient medical team, the length of stay (LOS) in the hospital, and communication between the inpatient team and their PCP. Information extracted from hospital administrative records included hospital charges, LOS, discharge location, and demographic characteristics. The Geri-FITT clinicians logged hours spent performing the clinical, educational, and administrative duties of the Geri-FITT model.


Study data were analyzed according to the intention-to-treat principle. Each respondent's CTM-3 score was computed based on the responses to the three questions, converted to a 0- to 100-point scale. CTM-3 scores and satisfaction data were analyzed using bivariate associations using cross tabulations, the chi-square statistic and Fisher exact test for categorical variables, and t-tests for continuous variables (assuming unequal variances).

The study was powered to detect a difference in mean CTM-3 scores of at least 3±14 points between the Geri-FITT and control groups (80% power, two-tailed test, alpha=0.05), requiring sample sizes of at least 300 in each group. The CTM-3 performs on the same scale as the CTM-15, with similar expected effect sizes (personal communication, E. Coleman).

A multivariable linear regression model of the relationship between hospital service (Geri-FITT or usual care) and CTM-3 score 14 days after discharge was constructed. Covariates in the model adjusted for the possible effects of baseline differences between the two groups (LOS) and factors that might a priori affect CTM-3 scores (age, sex, race or ethnicity, marital status, and Medicaid enrollment). Data on educational level, correlated with Medicaid enrollment, contained too many missing values (45.8%) to include in the model. The investigators also entered into the model interaction terms hypothesized a priori to represent possible synergies between receipt of care on a Geri-FITT service and patient characteristics (race or ethnicity and marital status). STATA statistical software version 9.0 was used for data analyses (StataCorp, College Station, TX).


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  2. Abstract

As shown in Table 1, the mean age of the Geri-FITT group was slightly older than that of the control group (79.7 vs 79.1, P=.18), and more Geri-FITT patients than usual care patients had a LOS of 7 days or longer (30.3% vs 23.7%, P=.05). Neither finding was statistically significant. There were no significant differences between the Geri-FITT and control groups in sex, race or ethnicity, marital status, education level, Medicaid enrollment, primary diagnosis, discharge disposition, or hospital charges.

Table 1. Characteristics of Study Population
CharacteristicAll Participants (n=717)Control (n=351)Geri-FITT (n=366) P-Value*
  • *

    Comparison between Geriatric Floating Interdisciplinary Transition Team (Geri-FITT) and control using t-test for comparison of means (assuming unequal variances) and chi-square or Fisher exact test for comparison of proportions.

  • There were 328 missing values for education because these were gathered using self-report (n=388).

  • LOS=length of stay; SE=standard error.

Age, mean (SE)79.4 (0.2)79.1 (0.3)79.7 (0.3).18
Age, %   .09
Sex, %   1.00
Race or ethnicity, %   .17
Marital status, %   .20
Education, %   .36
 ≤High school education76.677.775.6 
 >High school education23.422.324.4 
Medicaid enrollment, %25.823.927.6.15
Primary diagnosis congestive heart failure, %
Discharge disposition, %   .27
 Home health11.212.89.6 
LOS, days, mean (SE)5.8 (0.3)5.6 (0.4)5.9 (0.4).65
LOS, days, %   .05
Hospital charges, $1,000, mean (SE)16.4 (9.0)16.0 (12.2)16.8 (13.1).65

The Quality of Care Transitions

In bivariate analysis, the group mean (standard error (SE)) CTM-3 score (range 0–100) was 76.3 (1.5) for the Geri-FITT group and 73.1 (1.9) for the control group (P=.19). In bivariate analysis, nonwhite race was associated with higher CTM-3 scores. In a multivariable linear regression model, Geri-FITT exposure was not significantly associated with care transition quality (B=1.81, SE=2.51, P=.47) after adjustment for age group, sex, race or ethnicity, marital status, Medicaid enrollment, and LOS (Table 2). The addition of interaction terms did not significantly change the model (study group and minority status P-value for likelihood ratio test (LRT)=.61, study group and marital status P-value for LRT=.12).

Table 2. Multiple Linear Regression Model of the Relationship Between 14-Day Postdischarge Three-Item Care Transitions Measure Scores and Model of Care (n=269)
Characteristic β Coefficient (Standard Error)95% Confidence Interval P-Value
Geriatric Floating Interdisciplinary Transition Team model (reference=control)1.81 (2.51)−3.14–6.76.47
Aged >85 (reference=70–85)−0.59 (2.84)−6.18–4.99.84
Female (reference=male)4.09 (2.67)–1.16–9.34.13
Nonwhite (reference=white)6.59 (2.65)1.37–11.80.01
Unmarried (reference=married)5.03 (3.03)−0.94–10.99.10
Medicaid enrollment (reference=no enrollment)0.86 (2.91)−4.87–6.58.81
Length of stay ≥7 days (reference= 0–6 days)0.72 (2.98)−5.16–6.59.81

Satisfaction with Care

Respondents in both groups reported high levels of satisfaction with care; small differences between the two groups were not statistically significant. Slightly more patients exposed to the Geri-FITT model were satisfied or very satisfied with the quality of their inpatient medical care (95.2% vs 93.8%, P=.21), overall quality of the inpatient services (95.2% vs 92.4%, P=.45), PCP knowledge of what happened to them in the hospital (76.7% vs 72.2%, P=.16), and LOS (72.3% vs 66.4%, P=.42).


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  2. Abstract

Feasibility of Implementation

This pilot study demonstrates a feasible model using a geriatric nurse practitioner–geriatrician team to augment providers' limited inpatient geriatrics expertise by combining evaluation and comanagement with transitional care service. By “floating” to where patients were admitted for medical and nursing care, the team was able to extend elements of a specialized geriatric medical service to several medical units, engage diverse healthcare professionals around patient-specific needs, and build a common purpose for providing optimal geriatric and transitional care. This was accomplished by providing care consistent with patient-identified goals, coordinating care across sites, and engaging important providers in the care transition process: inpatient and primary care physicians, nurses, discharge planners, patients, and caregivers. It may be noteworthy that LOS was slightly longer in the Geri-FITT group. This was not statistically significant, and future research is needed to determine whether this is an important finding, because this could be a barrier to adoption of the model. Possible reasons for this finding could include having sicker patients in the intervention group or time needed for additional evaluation and management of newly identified geriatric syndromes.

This model was compared with a recently developed “floating” outpatient geriatrics consultation team.41 The authors found that the addition of an interdisciplinary geriatric team was acceptable to PCPs and had some effect on care of geriatric conditions but little effect on patient function or use of inpatient care. The study did not report on care transition quality or satisfaction with care. Geri-FITT is a comanagement, not consultative, model that additionally delivers transitional care. The models have overlapping but different goals, limiting further comparison.


These data represent findings from a 1-year pilot study designed to assess feasibility and early effects of the Geri-FITT model on care transition quality and patient satisfaction with inpatient care. Several limitations are noted. First, this pilot was executed at a single site and used a small sample, limiting generalizability of the findings. Second, this institution had access to geriatric medicine providers, but a dearth of such providers nationwide may be a barrier to dissemination of the model in its current form. Third, the initial implementation period for this study was short (3 months) and thus may have missed benefits that occur with maturity of the model. Fourth, the intervention may have affected other outcomes not measured by the CTM-3. Fifth, many of the participants had difficulty understanding some of the CTM-3 questions; thus, there may have been differences in how the CTM-3 performed in this study setting. Finally, the completion rate for the study was limited. After accounting for attrition, the study eventually did not have sufficient power to detect a 3-point difference in mean CTM-3 scores. Completers and noncompleters did not differ significantly in age, sex, race or ethnicity, marital status, education, or Medicaid enrollment, but completers were more likely to have been discharged to home (69.9% vs 55.1%, P<.001) and less likely to have a LOS of 7 days or longer (22.7% vs 29.7%, P=.02). Noncompleters were more likely to be discharged to locations other then home and have a longer LOS. These were likely to be patients requiring more-complex medical and nursing care who would potentially have benefited from the intervention; thus the lack of inclusion of their responses probably biased the results toward the null hypothesis.

Implications of Findings

Improvement of care coordination has relevant ethical and legal implications for hospitals and providers. For example, hospitalists have a duty to provide patient care until the handoff is complete,42 and the American College of Physicians has stated that provider handoffs are an ethical issue.43 An important component of the Geri-FITT model is to facilitate the handoff to the PCP in a prompt and seamless manner. The GNP conveys key information to the PCP directly, ensuring that important information is not missed (e.g., pending test results, medication changes, geriatric syndromes). Lack of such communication has been the basis for liability lawsuits against emergency department physicians and radiologists.42

The Geri-FITT model has the potential to positively affect hospital reimbursement—even without reducing LOS—if the model can be shown to reduce avoidable readmissions. For example, the Centers for Medicare and Medicaid Services may soon hold hospitals and providers accountable for patient utilization and outcomes within the first 30 days of discharge.44 This has implications for delivering high-quality transitional care and increases the value of interventions that improve care transitions and reduce hospital readmission. Furthermore, models that incorporate hospital staff education about geriatric syndromes provide another potential mechanism for leveraging limited geriatric medicine expertise, thereby enhancing the geriatric competence of the workforce, which is a national goal.40 Finally, with the advent of public reporting of quality measures, hospitals care about increasing patient satisfaction with the hospital experience. Geri-FITT and similar models that have the potential for improving care transition quality may enhance patient satisfaction. The Vice President and Chief Financial Officer of Johns Hopkins Medicine offered this perspective: “Geri-FITT is a wonderful example of bringing different kinds of caregivers together for the purpose of improving outcomes and lowering costs. We are confident this model will result in less service utilization and hospital readmission while improving geriatrics skills, clinical outcomes, and patient satisfaction” (R. Grossi, personal communication). Future research is needed to determine whether savings accrued are sufficient to offset the costs.


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The following individuals contributed to this work: Linda Fried, MD, MPH, model design; Danelle Cayea, MD, MS, model design, educational intervention, clinical education; Jeremy Barron, MD, MPH, and Erwin Tan, MD, clinical educators; Deborah Statom, manuscript preparation; William Carruth, MBA, Kate Walls, MBA, Amina Burthéy, MHSA, Jeanette Ravendhran, and Gina Ray, MHA, financial and administrative data; Chris Cobbs, data management; Myron Weisfeldt, MD, and Ron Peterson, institutional support; and Mary Naylor, PhD, RN, and Eric Coleman, MD, MPH, model design. Salary support for Dr. Arbaje: Robert Wood Johnson Foundation, John A. Hartford Foundation. Support for Dr. Durso: Miller-Coulson Scholar, Center for Innovative Medicine.

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. This study was funded by the John A. Hartford Foundation, the Secunda Family Foundation, and the Johns Hopkins Hospital Department of Medicine.

Author Contributions: Study concept and design (AIA, VIW, ET, CB, KJE, SCD). Acquisition of subjects and/or data (AIA, DDM, VIW, KJE). Analysis and interpretation of data (AIA, DDM, QY, VIW, ET, CB, KJE, SCD). Preparation of manuscript (AIA, DDM, QY, VIW, ET, CB, KJE, SCD).

Sponsor's Role: The sponsors had no role in the design, methods, subject recruitment, data collections, analysis, or preparation of this manuscript.


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