How an Interdisciplinary Care Team Reduces Prolonged Admissions Among Older Patients with Complex Needs

Kenneth Lam
Erika L. Price
Megha Garg
Nate Baskin
Megan Dunchak
Sarah Hooper
Anne Fabiny
Jessica A. Eng
Case Example
August 2021


An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.


To address barriers to discharge and improve care coordination for older adults with complex needs, the San Francisco Veterans Affairs Health Care System formed the Transitions Referral and Coordination (TRAC) team in 2019. With representation from inpatient and outpatient services, medical-legal partnership, nursing, and social work leadership, the TRAC team met weekly to review and make recommendations for complex discharge cases and standardize data collection.


The TRAC team reviewed patients and identified issues that were prolonging hospitalizations, such as cognitive impairment, substance use, and housing instability. The team then developed solutions to address these issues, such as using the inpatient geriatrics service to assess capacity around complex discharge decisions and assess the safety of the outpatient living environment and involving medical-legal partnership attorneys to evaluate patient capacity for decision-making or provide counsel to patients around social and financial issues. Over six months, the health system observed a 40 percent reduction in the number of patients with a length of stay longer than 30 days. Furthermore, a survey of team members and referring providers also revealed that the TRAC framework is extremely valuable to providers and care team members as they work collaboratively to improve care for inpatients with complex needs.


Promoting an interdisciplinary team-based approach and investing in time and resources for all relevant parties to discuss and coordinate care for patients with complex needs can lead to higher quality of care and possible savings for health systems and health plans from reductions in hospital stays.

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