The Health Optimization Program for Elders (HOPE) is a service focused on enhancing transitions in care for older adults (55+). It is a collaborative, inter-professional effort involving:   Division of Geriatrics, Case Management, the Hospital Medicine program,  Duke University School of Nursing, Duke NICHE, and Skilled Nursing Facilities (SNF). The HOPE team provides expertise in navigating the post-acute and long-term care setting while optimizing coordination of care for patients transitioning from the hospital setting to the SNF setting, with the goal of reducing avoidable readmissions to the acute care setting.

The program began with identifying factors contributing to readmissions and sharing this information with hospital and SNF stakeholders. As a result, the team has implemented the following:

•             Quarterly SNF/DUHS stakeholder meetings

•             Monthly operational team meetings

•             HOPE-specific geriatric consult process

•             Post-transition communication processes between hospital and SNF providers 

•             Readmission case review processes, both from the acute care and SNF perspective


Based on the case review processes, the HOPE team is currently developing interagency, interprofessional web-based educational modules addressing strategies to more effectively engage patients and families in shared decision making.