Background
Demand on health services
Quality indicator | Definition of indicator |
---|---|
Effectiveness | |
Efficiency | Efficient care is care without waste, including wasted resources [4]. |
Timeliness | Timely care is care that is provided in a timely manner without lengthy waiting periods for patients and their family [4]. |
Safety and risk | |
Equity | Care that is fair to everyone. No group of people receive inferior care based in differences in gender, culture, ethnicity, age, sexuality, geographic location or socioeconomic status [4]. |
Person and family centred care and experience |
Transitional care
What is currently known about quality transitions?
Objectives
Methods
Search strategy
Inclusion criteria
Screening procedure
Data extraction
Assessment for risk of bias
Results
First author (year) | Reason for exclusion |
---|---|
Arbaje (2010) [43] | Quasi-experimental design |
Bull (2000) [44] | Not a full transitional care intervention, discharge planning |
Balaban (2008) [45] | Adult sample, not focussed on older people with functional difficulty |
Bonnet-Zamponi (2013) [46] | Secondary data analysis, drug related problems |
Brand (2004) [47] | Quasi-experimental design |
Coleman (2004) [48] | Quasi-experimental design |
Dedhia (2009) [49] | Quasi-experimental design |
Einstadter (1996) [50] | Not a full transitional care intervention, discharge planning |
Golden (2010) [51] | Not a full transitional care intervention, discussion paper |
Haggmark (1997) [52] | Not a full transitional care intervention, interprofessional care |
Ham (2011) [3] | Not a full transitional care intervention, integrated care |
Hansen (1992) [53] | Not a full transitional care intervention |
Hebert (2008a) [54] | Not a full transitional care intervention, integrated care |
Hebert (2008b) [55] | Not a full transitional care intervention, integrated care |
Hegney (2002) [56] | Not a full transitional care intervention, discharge planning |
Jack (2009) [57] | Adult sample, not focussed on older people with functional difficulty |
Jeangsawang (2012) [58] | Not randomised controlled trial or quasi-experimental design |
Lattimer (2012) [59] | Discussion paper |
Melton (2012) [60] | Adult sample, not focussed on older people with functional difficulty |
O’Reilly (2008) [61] | Rehabilitation, not transitional care |
Ornstein (2010) [62] | Mixed methods, not randomised controlled trial, not quasi-experimental design |
Parker (2004) [30] | Systematic review |
Parker (2009) [63] | Rehabilitation, not transitional care |
Parry (2008) [64] | Psychometric study, cross sectional design |
Steeman (2006) [65] | Quasi-experimental design |
Transitional care interventions
First author (year) | Setting, sample & study design | Stated aims | Intervention | Limitations |
---|---|---|---|---|
Discharge protocol & advanced practice nurse
| ||||
Naylor (1990) [72] | US, acute inpatient (medical, surgical) to home | To test a protocol of discharge planning compared with standard hospital discharge | Protocol implemented by advanced practice nurses (APN): | Small sample size |
Costs of nursing intervention was incomplete due to missing data | ||||
N = 40, average age 78.8 years | ||||
Assessment and discharge planning within 24 hours of admission | ||||
Chronic illness | Discharge plan included health teaching to be conducted in primary care | |||
RCT | ||||
APN telephone follow up for 2 weeks post discharge | ||||
Naylor (1994) [68] | US, acute inpatient (medical, surgical) to home | To assess an APN implemented discharge planning protocol compared with standard hospital discharge | Discharge planning protocol implemented by APNs: | Generalizability of findings is limited to older people with cardiovascular diagnoses, oriented and alert at admission, well educated, with good support systems and few functional deficits |
Discharge assessment 24–48 hours after hospital admission | ||||
Discharge plan developed collaboratively with client, carer, multidisciplinary team | ||||
N = 276, average age 76 years | ||||
Communication and coordination maintained by APN throughout this process with multidisciplinary team including primary care providers | ||||
Chronic illness | ||||
RCT | ||||
Post discharge APN phone availability | ||||
Naylor (1999) [77] | US, acute inpatient (medical, surgical) to home | To assess an APN implemented discharge planning protocol compared with standard hospital discharge for older people at risk of re-hospitalization | APN protocol discharge planning and home support follow up: | Generalizability of findings is limited to older people oriented and alert at admission |
APN care continuity | ||||
Intervention may be limited to deployment by advanced practice nurses in primary care | ||||
APN conducted hospital discharge planning care and in home support (substituted for the visiting nurse) for the first 4 weeks post discharge | ||||
N = 363, average age 75.4 years | ||||
APN individualised patient care in collaboration with the person’s physician | ||||
Chronic illnesses | ||||
RCT | ||||
Naylor (2004) [75] | US, acute care to home | To assess the effects of an advanced practice nurse delivered transitional care intervention on older people with heart failure and comorbid conditions | Advanced practice nurse conducted a transitional care intervention emphasising | Generalizability of findings is limited to older people with exacerbation of cardiac failure and co morbid conditions |
N = 239, average age 76 years | Discharge assessment | |||
Intervention may be limited to deployment by advanced practice nurses | ||||
Discharge plan | ||||
Discharge coordination with multidisciplinary team | ||||
APN care continuity | ||||
Education | ||||
Heart failure and comorbid illnesses | Symptom management and self-management | |||
Goal setting | ||||
Medication management | ||||
Home visits/home nursing up to 3 months following discharge | ||||
RCT | ||||
Enguidanos (2012) [74] | US, acute care to home | To assess impact of brief nurse practitioner (NP) intervention for older people discharged from hospital to home compared with standard hospital discharge | NP in primary care conducted: | Sample size insufficiently powered to detect an effect of the intervention |
Education about discharge instructions to older person | ||||
Intervention may be limited to deployment by nurse practitioners | ||||
N = 199, average age 73.58 years | Medication reconciliation | |||
Home care needs assessment and referral to resources | ||||
Scheduling follow-up medical appointments | ||||
Chronic illnesses | ||||
RCT | ||||
General practitioner and primary care nurse models
| ||||
Weinberger (1996) [67] | US, acute care to home | To test an primary care intervention on rates of re-hospitalization, length of stay, quality of life and veteran satisfaction compared with standard discharge care | Before discharge: | Generalizability of study limited to older US male veterans |
The primary care nurse conducted the discharge assessment, provided education and the contact telephone numbers of the primary care nurse and general practitioner (GP), and scheduled an appointment within 2 days of discharge to attend the primary care clinic | Substantial primary care resources were required to implement the intervention | |||
N = 1396, average age 63 years, veteran sample, mostly male (98.5%) | ||||
The GP visited the veteran in hospital within 2 days prior to discharge and reviewed the discharge plan, medication, and medical problems with the hospital physicians | ||||
Chronic illnesses | After discharge: | |||
The primary care nurse telephoned the patient (within 2 working days of discharge) at home to assess any difficulties with medications/medical treatments, health problems, remind of follow-up appointment | ||||
Patients were followed-up in clinic | ||||
The primary care nurse and GP reviewed treatment plan at first appointment. | ||||
RCT | ||||
McInnes (1999) [73] | Australia, acute hospital-geriatric care unit (patients admitted under care of geriatrician) to home | To test if GP involvement in discharge planning patient outcomes when compared with standard hospital discharge | Standard hospital discharge practice with the addition of GP visit pre discharge: | Of those randomized to the intervention group only 52% of patients were actually visited by their GP in hospital |
GPs invited to undertake pre discharge visit: | ||||
N = 364, average age 81 years | Substantial primary care resources were required | |||
Information sought from GP re recommendations for post discharge care | ||||
RCT | ||||
GP able to discuss care/treatment with hospital based medical and allied | ||||
health staff | ||||
GP had access to the patient’s hospital care record during the visit | ||||
Preen (2005) [66] | Australia, acute hospital to home | To test a hospital coordinated discharge plan that involved the GP when compared with standard hospital discharge | Research nurse based in the hospital: | Intervention was not fully implemented as only 42% of GPs returned the discharge plan to the hospital prior to discharge |
Developed discharge plan (determined client discharge problems, goals and community service provider involvement) | ||||
Sample size may have been insufficiently powered to detect an effect of the intervention | ||||
Faxed the discharge plan to the GP 24–48 hours prior to discharge | ||||
N = 189, average age 75 years | The GP | |||
Reviewed the discharge plan, modified it and returned it to the hospital by fax | ||||
Chronic illnesses | ||||
Research nurse based in the hospital: | ||||
Explained the discharge plan to the client | ||||
RCT | Provided copies of the discharge plan to the client, and all service providers identified on the care plan. | |||
Scheduled an appointment with the GP | ||||
Self-management and transition coaching
| ||||
Coleman (2006) [69] | US, acute hospital to home | To assess the effects of a care transitions intervention in comparison with standard hospital discharge care, using RCT design, on rehospitalisation rates for older people | Care Transitions Intervention (as per Coleman et al. 2004 above) Intervention developed from qualitative research with older people and their care givers about what would be most valuable to them during care transitions: | Intervention may be limited to deployment by advanced practice nurses in the role of transition coach |
N = 747, average age 76 years | ||||
Medication assistance and self-management | ||||
Chronic illnesses | Patient centred and owned record | |||
Timely follow-up from primary care providers | ||||
RCT | List of problem triggers indicating deterioration in their particular chronic illness and what to do about these | |||
Discharge case management
| ||||
Lim (2003) [76] | Australia, acute hospital to home | To test the effects of case management and post acute care services on organisation and patient/caregiver outcomes in comparison with standard hospital discharge | Post Acute Care program: | Costs were averages of community services and daily hospital bed utilisation rates, actual costs for each individual were not captured |
Short term case management and provision of post-acute care services (in home) nursing, allied health, community supports | ||||
N = 598, average age 76 years | ||||
Chronic illnesses | ||||
RCT | ||||
Inpatient geriatric evaluation, co-management (with ward staff) and transitional care
| ||||
Hansen (1995) [70] | Denmark, subacute geriatric ward to home | To compare the intervention with standard hospital discharge on the number of medical and social problems after discharge, the need for modification of the discharge plan after discharge and rates of re-hospitalization to hospital | The Geriatric Evaluation and Management team (geriatrician, nurse and physical therapist) supported inpatient discharge planning and follow-up at home | Generalizability of findings limited to older people with low functioning |
N = 193, average age intervention 78 to 80 years | Intervention may be limited to deployment by geriatricians | |||
Follow-up involved re-evaluation and modification of the care plan, communication with the primary care team (GP, community nurse) during home visits at 1, 3, 8, 16 weeks following discharge | ||||
Multiple chronic conditions and low functional status | ||||
RCT | ||||
Legrain (2011) [71] | France, acute inpatient geriatric care unit to varying locations: home, nursing home, rehabilitation unit, acute care unit | To compare a comprehensive discharge intervention with standard hospital discharge on emergency department visits and re-hospitalisations | Geriatrician delivered inpatient intervention: | Findings generalizable to functionally dependent older people |
Medication review | ||||
Education re self-management of disease | ||||
Communication principally with GP | Intervention may be limited to deployment by geriatricians | |||
Screening for main risks for frail elderly | ||||
Depression | ||||
N = 665, average age 86 years | ||||
Chronic illnesses | ||||
RCT |
Outcomes
First author (year) | Main findings |
---|---|
Discharge protocol & advanced practice nurse
| |
Naylor (1990) [72] | Significant reduction in rates of re-hospitalization for intervention group over the 12 weeks post discharge |
No difference in length of stay | |
No difference in posthospital infections | |
Naylor (1994) [68] | Intervention patients in the medical units at 6 week follow-up experienced: |
Significant delay in re-hospitalization to hospital | |
Fewer total days of re-hospitalisation | |
Lower health care costs (inclusive of inpatient, clinic, home visits) | |
No change in functional status, mental status, self-esteem or affect | |
Intervention caregivers up to 12 weeks following discharge experienced: | |
No change in functional status, caregiving demands, family | |
functioning, affect | |
Naylor (1999) [77] | Intervention group at 24 week follow-up experienced fewer: |
Re-hospitalizations | |
Hospital days per patient | |
Lower costs than control group | |
No statistically significant differences in functional status, depression or patient satisfaction between groups | |
Naylor (2004) [75] | The time to first admission was longer in intervention patients |
At 52 weeks, intervention patients had fewer re-hospitalizations and lower total mean costs | |
There were short term improvements among intervention patients in quality of life (physical domain, up to 12 weeks post discharge) and satisfaction with discharge and transition care (up to 6 weeks post discharge) | |
Enguidanos (2012) [74] | No change in re-hospitalization rates at 6 months following enrolment in the study |
The intervention group experienced significantly fewer visits to GPs | |
There were no changes between intervention and control groups in self-efficacy or satisfaction with service | |
General practitioner and primary care nurse models
| |
Weinberger (1996) [67] | At 6 months following discharge: |
Intervention group had significantly higher rates of re-hospitalization and if re-admitted longer in hospital stay than controls (discharge as usual). | |
Intervention group were significantly more satisfied with their care than controls | |
No differences in quality of life scores between groups | |
Quality of life scores were low in both groups | |
McInnes (1999) [73] | At 6, 12, 26 weeks following discharge: |
No significant differences in length of stay, rates of re-hospitalization or time to first re-hospitalization | |
Intervention patients were significantly more likely to be | |
Referred to community services at discharge and report that hospital staff had discussed their discharge plan with them | |
Intervention patients reported increased satisfaction with discharge arrangements and preparation | |
Preen (2005) [66] | There were no differences in length of stay between groups |
One week following discharge: | |
GPs in the intervention group were more satisfied with the documentation | |
Discharge communication to GPs in the intervention was significantly faster than for GPs in the control group | |
Patients in the intervention group reported improved satisfaction with discharge planning, access to health services, confidence with discharge, and mental quality of life | |
Self-management and transition coaching
| |
Coleman (2006) [69] | Intervention group had significantly lower re-hospitalization rates than the control group at 30, 90 and 180 days post discharge |
Intervention group had significantly lower hospital costs than the control group at 30, 90 and 180 days post discharge | |
Discharge case management
| |
Lim (2003) [76] | Over 6 month follow-up period there were no differences in rates of unplanned re-hospitalizations |
Intervention patients had significantly reduced length of stay (index hospitalisation) | |
Costs (hospital utilisation) lower in intervention patients over 6 | |
months following discharge | |
No differences in costs (utilisation of community services) | |
between groups | |
Significantly improved self-reported quality of life in intervention patients at one month follow-up | |
No difference in caregiver burden at 1 month follow-up | |
Inpatient geriatric evaluation, co-management (with ward staff) and transitional care
| |
Hansen (1995) [70] | At 6 months following discharge: |
People in the intervention group were significantly less likely to be re-admitted to hospital than those in the control group | |
There were no differences in rates of admission to nursing homes or mortality rates | |
Significant increase in new and unforseen problems identified following discharge in people receiving the intervention. | |
Intervention participants were significantly more likely to be allocated home help. | |
Legrain (2011) [71] | Older people in the intervention group were significantly less likely to attend the emergency department or be re-admitted at 3 months following discharge |
There were no differences between groups in ED attendances or re-hospitalizations at 6 months following discharge |
First author (year) | Quality indicators assessed in study outcomes | |||||
---|---|---|---|---|---|---|
Effectiveness | Efficiency | Timeliness | Safety & risk | Equity | Person & family centred care | |
• Discharge protocol & advanced practice nurse
| ||||||
Naylor (1990) [72] | ✔ | ✔ | ✔ | |||
Naylor (1994) [68] | ✔ | ✔ | ✔ | |||
Naylor (1999) [77] | ✔ | ✔ | ✔ | ✔ | ||
Naylor (2004) [75] | ✔ | ✔ | ✔ | ✔ | ||
Enguidanos (2012) [74] | ✔ | ✔ | ✔ | ✔ | ||
• General practitioner and primary care nurse models
| ||||||
Weinberger (1996) [67] | ✔ | ✔ | ✔ | ✔ | ||
McInnes (1999) [73] | ✔ | ✔ | ✔ | ✔ | ✔ | |
Preen (2005) [66] | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
• Self-management and transitional coaching
| ||||||
Coleman (2006) [69] | ✔ | ✔ | ✔ | |||
• Discharge case management
| ||||||
Lim (2003) [76] | ✔ | ✔ | ✔ | |||
• Inpatient geriatric evaluation, co-management and transitional care
| ||||||
Hansen (1995) [70] | ✔ | ✔ | ✔ | ✔ | ||
Legrain (2011) [71] | ✔ | ✔ | ✔ |
Efficiency, effectiveness and safety
Person and family centred care
Timeliness and equity
Bias assessment
Risk of bias | |||||||
---|---|---|---|---|---|---|---|
Selection bias1
| Performance bias2
| Detection bias3
| Attrition bias4
| Reporting bias5
| Other bias6
| ||
First author (year) | Random sequence generation | Allocation concealment | Blinding of participants and personnel | Blinding of outcome assessment | Incomplete outcome data | Selective reporting | Other sources of bias |
Coleman (2006) [69] | Low risk | Unclear risk | Unclear risk | Low risk | Low risk | Low risk | Low risk |
Enguidanos (2012) [74] | Low risk | Low risk | Unclear risk | Low risk | High risk (self-efficacy, service satisfaction) Low risk (service utilisation) | Low risk | Low risk |
Hansen (1995) [70] | Low risk | Unclear risk | High risk (personnel) Unclear risk (participants) | Unclear risk | Unclear risk | Low risk | Unclear risk |
Legrain (2011) [71] | Low risk | Low risk | High risk (personnel) Unclear risk (participants) | Unclear risk | Unclear risk | Low risk | Unclear risk |
Lim (2003) [76] | Low risk | Low risk | Unclear risk | Low risk | Unclear risk | Low risk | Unclear risk |
McInnes (1999) [73] | Low risk | Low risk | Unclear risk | Low risk (service utilisation data) Unclear risk (questionnaire data) | Unclear risk | Low risk | Unclear risk |
Naylor (1990) [72] | Low risk | Low risk | High risk (personnel) Unclear risk (participants) | Unclear risk | Unclear risk | Low risk | Unclear risk |
Naylor (1994) [68] | Unclear risk | Unclear risk | Unclear risk | Unclear risk | Unclear risk | Unclear risk | Unclear risk |
Naylor (1999) [77] | Low risk | Low risk | High risk (personnel) Unclear risk (participants) | Low risk | Unclear risk | Low risk | Unclear risk |
Naylor (2004) [75] | Low risk | Low risk | High risk (personnel) Unclear risk (participants) | Low risk | Unclear risk | Low risk | Low risk |
Preen (2005) [66] | Unclear risk | Unclear risk | Unclear risk | Unclear risk | Unclear risk | Low risk | Unclear risk |
Weinberger (1996) [67] | Unclear risk | Low risk | Unclear risk | Low risk | Unclear risk | Low risk | Unclear risk |