Vanesa Amaro
Transitional Care Unit, General Acute Hospital,
Argentina
Abstract Title:
From Acute public Hospital Care to Transitional and Progressive Care Models for Vulnerable Older Adults in Argentina
Biography:
Dr. Vanesa Amaro is a geriatrician and psychiatrist. Both have clinical and managerial experience in vulnerable older adult care, transitional care, long-term care facilities, and comprehensive geriatric assessment. Their work focuses on continuity of care, frailty, multimorbidity, functional decline, dependency, caregiver support, and the design of interdisciplinary person-centered care models for older adults requiring integrated clinical, functional, and social support following acute hospitalization.
Research Interests:
Background Argentina faces accelerated population aging, with growing pressure on its public hospital system. In Buenos Aires representative of national trenadas — an estimares 25–40% of hospitalized older adults present with frailty, multimorbidity, functional decline, and severe social vulnerability: absent caregiver networks, inadequate or unsafe housing, and limited community resources. Once the acute episode resolves, these patients frequently remain hospitalized not due to clinical necessity, but because safe discharge is not feasible. Placement in long-term care facilities through social insurance (obras sociales) involves waiting periods of eight months or more.Prolonged hospitalization generates avoidable complications including immobility syndrome, sarcopenia, pressure ulcers, hospital-acquired infections, functional deterioration, and iatrogenic dependency.
Objective: To analyze and propose a transitional care model bridging acute public hospital admission and appropriate continuing-care devices for vulnerable older adults in Argentina, using Buenos Aires public hospitals as the primary reference with potential national replication.
Methods/Approach: A conceptual analysis and care model proposal were developed, integrating geriatric medicine, functional rehabilitation, social work, mental health, case management, family support, and health-system coordination, grounded in comprehensive geriatric assessment and interdisciplinary frameworks adapted to public-sector constraints.
Proposed Model: A transitional care unit approved and operational since late 2025 vas designed for clinically stable patients meeting discharge criteria but facing unresolved social, functional, or housing barriers. Core components include comprehensive geriatric assessment, physical and cognitive rehabilitation, nutritional support, psychosocial and psychiatric intervention, nursing care, discharge planning, and coordinated referral to primary care, home care, day hospitals, long-term care facilities, or palliative care.
Conclusion: Transitional care modeles embedded in public hospitals can reduce avoidable prolonged admissions, prevent hospitalization-associated complications, preserve autonomy, support caregivers, and optimize scarce public resources — offering a replicable, person-centered response to the growing care gap for vulnerable older adults in Argentina.
Keywords: Vulnerable older adults; Transitional care; Prolonged hospitalization; Long-term care models; Comprehensive geriatric assessment
