Understanding transitional care programs for older adults who experience delayed discharge: a scoping review

Many older adults live with multiple complex health problems or experience unforeseen circumstances (e.g., falls) that result in acute care hospital admissions. Among hospitalized older adults, some cannot be discharged once intensive medical treatments are completed because they lack sufficient health and social supports (e.g., community services, nursing home beds) to meet their post-acute care needs [1]. Delayed discharges—episodes where patients have to stay in an acute care bed for longer than medically necessary—present critical challenges for many health care systems [2]. In Canada, patients who experience delayed discharge are referred to as Alternate Level of Care (ALC), and they occupy 8 to 10% of acute care hospital beds [3].

Delayed discharges are an important health issue on both an individual and health system levels. McCloskey and colleagues [4] found that mean age of this group was 79 years; 65% were women; had a mean of 4.6 chronic conditions (mainly hypertension, heart disease and diabetes); and were on multiple medications. During their hospital stay, most showed functional decline (reduced mobility and ability to perform basic activities of daily living); had inadequate home support both prior to admission and following discharge from hospital; and were waiting for transfer to a long-term care facility [5]. These older patients often developed complications (e.g., poor oral intake, confusion, infections), felt socially isolated [1] and, alongside their care partners, reported increased depressive [3], anxiety, and stress symptoms [5, 6]. Also, some hospitals charge patients with a daily co-payment for prolonged delayed discharge, which may contribute to a substantial financial burden on individuals and families [6]. At the system level, delayed discharges reduce patient flow, leading to emergency department overcrowding, cancelled elective outpatient surgeries, and poor coordination of care resources across healthcare settings [1, 3].

To address these issues, healthcare systems globally have introduced programs to provide primarily restorative care, to older patients either experiencing, or at risk for, delayed discharge. These programs serve as a means to maintain continuity of care in the interface between acute care and other settings such as residential care or an individual’s home. These programs include Intermediate Care Models (ICMs) in the UK and Europe; sub-acute care, post-acute care or skilled nursing facilities (SNFs) in the US; and Transitional Care Programs (TCPs) in Australia and Canada, which will all hereafter collectively be referred to as TCPs. TCPs are designed to provide short term, low intensity, restorative care to older adults (aged 65+) who are medically fit to leave the hospital but are unable to do so due to multiple issues including hospital acquired deconditioning and lack of social supports in the community [3]. Differences in TCPs across countries makes it difficult to describe and compare the patient populations they serve, the services they offer, the resources required to deliver them, and their expected outcomes [7]. To address this concern, Sezgin et al. [8] identified and defined the characteristics of ICMs based on the results of a scoping review and an international expert consultation (Delphi study and consensus meeting); the study identified key defining features of ICMs, including time-limited care delivered by interdisciplinary teams that promote recovery, restore independence and act as the interface between acute care services and home. In a subsequent review focused on the effectiveness of ICMs, Sezgin et al. [9] found that while some researchers reported reduced hospital utilisation, evidence was limited on the ICMs’ effectiveness in reducing emergency readmissions, institutionalization and cost, or improving older adults’ function. The inconsistent findings may be attributable to contextual factors (i.e., characteristics of patients, staff and environment) that may influence the implementation and outcomes of TCPs [10]. Contextual factors may impact the actual delivery of the TCPs’ core components which are aimed at reducing and preventing delayed hospital discharges in older adults, and with achieving best outcomes for this population.

This scoping review was conducted to describe contextual factors and core components of TCPs, and outcomes used to evaluate TCPs. The review was informed by Donabedian’s structure-process-outcome framework [11]. Structures are defined as attributes or characteristics that are within the health care team, organization, or patient that influence the implementation of the core components or services and the outcomes of TCPs. For example, in the current context, the patient structure covers the characteristics of older patients admitted to TCPs, and the resources (i.e., healthcare team) needed for providing high-quality services. Processes represent the core components and specific services offered, as well as the behaviours or actions reflecting collaboration between the individuals and their surroundings. For TCPs, examples of processes include the range of physical and psycho-social services provided by the TCP staff. Potential outcomes targeted at patients include functional status for patients, and the healthcare system outcomes such as discharge destinations, as healthcare system outcomes. Specifically, the purpose of this review was to identify research evidence and knowledge gaps related to the structures, processes and outcomes of TCPs. The specific review questions were:

A scoping review (ScR) is the most suitable method for knowledge synthesis to address our exploratory research questions [12]. We followed the ScR methodology framework outlined by Arksey and O’Malley [13] and refined by Levac et al. [14], Colquhoun et al. [12], and Daudt et al. [15] as outlined in the published study protocol [7]. We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for ScRs statement (see Additional file 1). The ScR framework includes six steps: 1) identifying the research questions (listed above); 2) identifying relevant literature; 3) study selection; 4) charting the data; 5) collating, summarizing and reporting the results; 6) consulting with key stakeholders and translating knowledge. Below we briefly summarize each step.

Despite TCPs being developed globally, how TCPs are defined, funded and what services they provide vary widely [58‐60]. Our review identified 37 articles describing and assessing TCPs for older adults. Within these studies, five types of programs were reported: intermediate, sub-acute and post-acute care; skilled nursing facilities and TCPs. Collectively, these programs provide short term, low intensity, restorative care to older adults who are at risk of, or designated as, delayed discharge; they are intended to promote recovery, restore independence, and provide the interface between acute care services and home [3, 8].

The papers included in this review suggest TCPs typically serve older women with multiple chronic conditions and some cognitive impairment, but who were living alone and functionally dependent before admission. This is consistent with a recent review [8] showing that these programs serve frail older adults with complex health needs, and they also found that this cohort can benefit from these services and that they can offer optimal health care services prior to transfer to the most suitable setting. Few studies reported if and how family members were involved in care and discharge planning. Given that most of these older adults were discharged home and, with limited resources in the community, family members are often involved in sustaining care once back home, this can be seen as a gap in service. Only three studies described follow-up care, either by phone call or home visit, to reinforce treatment recommendations or ongoing care (e.g., new treatments, counselling, referrals and care partner support).

Our review delineated common core components that have been integrated in TCPs internationally, including assessment, care planning, treatment, discharge planning, and education. However, the variability in the specific services offered within each component was interesting given that the programs had similar purposes. In terms of assessments, comprehensive geriatric assessments are the gold standard [61] when caring for older adults with multiple comorbid conditions yet only four TCPs were found to use them. Given the population served by TCPs, further research should focus on the benefits of integrating the comprehensive geriatric assessments and a more holistic approach to care.

The individual services offered in the treatment component of TCPs were also highly variable and were specific to the goals of and the population targeted by the program within the health care organization. The most frequently reported treatment focused on rehabilitation and included a focus on transfers, stair climbing, strength, and balance exercises. These activities are essential to regain function [9] and are foundational in TCPs. Missing from many of TCPs were services focused on patients’ social and mental health needs. Social vulnerability stemming from the accumulation of multiple and varied social problems, such as inequities , loss of social support and networks and socioeconomic status is a concern, in part because of the impact on health [62]. Future studies of TCPs should account for these social vulnerabilities, including in planning for discharge.

Staff delivering the intervention were of diverse disciplines and the staff mix or complement varied according to the specific treatments delivered. The most frequently cited staff working in the programs were physiotherapists and nurses. A review of intermediate models of care suggest that care should be delivered by an interdisciplinary team within an integrated health and social care system where a single contact point optimises services access, communication and coordination [8]. Notably absent from the teams were hearing and vision specialists; given the increasing number of older adults and age-related increased risk of dual sensory loss and its associated challenges [63], more screening and services are required.

As reported in the articles reviewed, the TCPs share goals similar to those of geriatric rehabilitation (GR) programs, including to improve functional capacity, promote activity and preserve functional reserve and societal participation [64]. We advocate the integration of the core principles of GR that also utilizes reablement approach [65] in the design of TCPs to enhance patient outcomes, in addition to refinement to the staff complement and processes currently in use in existing TCPs. Reablement approach not only focuses on improving functional abilities but also on maintaining current abilities and independence. Accordingly, TCPs should entail: 1) provision of person-centered care where the patients and care partners are actively involved in goal setting and care planning taking into account psychosocial and environmental factors. If older adults have reached a stage where they have lost their ability to participate in advance care planning (ACP) and goals of care discussions due to advanced stages of neurodegenerative diseases, their care partners should be engaged in such conversations while keeping the patients’ best interest at the core. Furthermore, goals should be operationalized with an appreciation of person’s abilities so that they are achievable, realistic and meaningful for patients and care partners [65]; 2) conduct of comprehensive geriatric assessments which incorporate the perspectives of patients as well as care partners to help tailor rehabilitation interventions to patients’ physical and social needs; 3) involvement of interdisciplinary team members (nurses, PT, OT, SLP and social workers) and clinicians who have training and experience in care of older adults with in-house ready access to providers such as NPs and/or geriatricians to assess and treat acute changes in conditions; 4) use of strategies utilizing restorative and compensatory methods [65]. TCPs are sometimes used to offload older adults from the hospital beds to another less expensive care setting without providing the care that is required, demanding careful attention to potential misuse of these programs [59]. Therefore, a careful review of the patients’ goals of care must be articulated in acute care prior to admission to the TCP to ensure patients are in the best location.

There was significant variability in the patient-level outcomes measured to evaluate the impact of TCPs, including functional, cognitive, quality of life and health status measures. Health system outcomes included discharge destination, costs and hospital stay (length of stay, readmission rates). These results are consistent with a recent review that found similar outcomes being used to evaluate ICMs [9]. Our review corroborates the finding that comparisons between various TCPs may be difficult given the multiple outcomes used to evaluate them [8, 9]. Moving forward, we emphasize the importance of clarifying the conceptualization of TCPs and mapping the outcomes to the TCP components; this would facilitate the identification of core outcomes that should be carefully and consistently operationalized to enable meaningful comparisons across TCPs within and across countries.

It is about time we pose the question, why do we continue to build TCPs that are often related to restoring excess disability that was caused by acute care? Is it not time to focus on improving the hospital experience for older adults, especially those with dementia? Based on a review of acute care practices [66], ageism exists and better acute care practices can occur upstream instead of focusing on repairing losses that occurred in hospitals. A focus on better home care options [67] may also reduce the need for these ever-increasing TCPs which are currently being developed worldwide. TCPs, regardless of their name or design should not serve as holding places for these complex, frail and vulnerable individuals waiting for LTC admission, but should include staff who can work with older adults to attain their unique and full restorative potential in maintaining their independence if there is potential to do so, while also meeting their holistic and social care needs which may include helping them come to terms with their lost function and end of life. The strengths of the scoping review include a comprehensive and systematic search of the literature which identified factors that may influence the implementation and outcomes of TCPs in addressing delayed hospital discharges for older adults. Still, there were limitations; in particular, some relevant articles may have been excluded by limiting the search to four languages.

TCPs can influence outcomes for hospitalized older adults, including helping them go back home. This review highlights the need to design TCPs to be delivered by interdisciplinary teams, accommodating persons with cognitive impairment and actively involving care partners. Clinicians, administrators and policymakers should collaborate to establish TCPs that proactively admit older adults at risk for delayed discharge, focus on optimizing functional ability, and incorporate individualized care planning and care coordination. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.