Health, Social, and Functional Characteristics of Older Adults With Continuing Care Needs: Implications for Integrated Care.

OBJECTIVE: To identify older adults who could benefit from integrated care, we examined (a) health, social, and functional characteristics of older, hospitalized adults who required continuing care on discharge and (b) associations between these characteristics and potentially unnecessary health care use.

METHOD: Personal characteristics were extracted from patient charts ( N = 214) and examined in relation to three outcomes: discharge to institutional care, unnecessary hospital stay (alternative level of care), and long hospital stay.

RESULTS: Twenty-nine percent of the sample was discharged to an institution, 32.7% was coded as alternate level of care, and 27.6% had a long length of stay. Independent predictors of potentially avoidable health care use were mental and behavioral issues, living alone, functional status, and preadmission concerns about the patient managing in the community.

DISCUSSION: High users of health care services were identifiable prior to hospital admission, supporting the use of community-based integrated care approaches.