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Kinard T, Brennan-Cook J, Johnson S, Long A, Yeatts J, Halpern D. Effective Care Transitions: Reducing Readmissions to Improve Patient Care and Outcomes. Prof Case Manag 2024; 29:54-62. [PMID: 38015801 DOI: 10.1097/ncm.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
PURPOSE/OBJECTIVES Care transitions from one setting to another are vulnerable spaces where patients are susceptible to complications. Health systems, accountable care organizations, and payers recognize that care transition interventions are necessary to reduce unnecessary cost and utilization and improve patient outcomes following a hospitalization. Multiple care transition models exist, with varying degrees of intensity and success. This article describes a quality improvement project for a care transition model that incorporates key elements from the American Case Management Association's Transitions of Care Standards and the Transitional Care Management services as outlined by the Centers for Medicare & Medicaid Services. PRIMARY PRACTICE SETTING A collaboratively developed care transition model was implemented between a health system population health management office and a primary care organization. FINDINGS/CONCLUSIONS An effective care transitions model is stronger with collaboration among core members of a patient's care team, including a nurse care manager and a primary care provider. Ongoing quality improvement is necessary to gain efficiencies and effectiveness of such a model. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Care managers are integral in coordinating effective transitions. Care management practice includes transition of care standards that are associated with improved outcomes for patients at high risk for readmission. Interventions inclusive of medication reconciliation, identification and addressing of health-related social needs, review of discharge instructions, and coordinated follow-up are important factors that impact patient outcomes. Patients and their health system care teams benefit from the role of a care manager when there is a collaborative, coordinated, and timely approach to hospital follow-up.
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Affiliation(s)
- Tara Kinard
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - Jill Brennan-Cook
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - Sara Johnson
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - Andrea Long
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - John Yeatts
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - David Halpern
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
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Tyler N, Hodkinson A, Planner C, Angelakis I, Keyworth C, Hall A, Jones PP, Wright OG, Keers R, Blakeman T, Panagioti M. Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes: A Systematic Review and Network Meta-Analysis. JAMA Netw Open 2023; 6:e2344825. [PMID: 38032642 PMCID: PMC10690480 DOI: 10.1001/jamanetworkopen.2023.44825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Importance Discharge from the hospital to the community has been associated with serious patient risks and excess service costs. Objective To evaluate the comparative effectiveness associated with transitional care interventions with different complexity levels at improving health care utilization and patient outcomes in the transition from the hospital to the community. Data Sources CENTRAL, Embase, MEDLINE, and PsycINFO were searched from inception until August 2022. Study Selection Randomized clinical trials evaluating transitional care interventions from hospitals to the community were identified. Data Extraction and Synthesis At least 2 reviewers were involved in all data screening and extraction. Random-effects network meta-analyses and meta-regressions were applied. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Main Outcomes and Measures The primary outcomes were readmission at 30, 90, and 180 days after discharge. Secondary outcomes included emergency department visits, mortality, quality of life, patient satisfaction, medication adherence, length of stay, primary care and outpatient visits, and intervention uptake. Results Overall, 126 trials with 97 408 participants were included, 86 (68%) of which were of low risk of bias. Low-complexity interventions were associated with the most efficacy for reducing hospital readmissions at 30 days (odds ratio [OR], 0.78; 95% CI, 0.66 to 0.92) and 180 days (OR, 0.45; 95% CI, 0.30 to 0.66) and emergency department visits (OR, 0.68; 95% CI, 0.48 to 0.96). Medium-complexity interventions were associated with the most efficacy at reducing hospital readmissions at 90 days (OR, 0.64; 95% CI, 0.45 to 0.92), reducing adverse events (OR, 0.42; 95% CI, 0.24 to 0.75), and improving medication adherence (standardized mean difference [SMD], 0.49; 95% CI, 0.30 to 0.67) but were associated with less efficacy than low-complexity interventions for reducing readmissions at 30 and 180 days. High-complexity interventions were most effective for reducing length of hospital stay (SMD, -0.20; 95% CI, -0.38 to -0.03) and increasing patient satisfaction (SMD, 0.52; 95% CI, 0.22 to 0.82) but were least effective for reducing readmissions at all time periods. None of the interventions were associated with improved uptake, quality of life (general, mental, or physical), or primary care and outpatient visits. Conclusions and Relevance These findings suggest that low- and medium-complexity transitional care interventions were associated with reducing health care utilization for patients transitioning from hospitals to the community. Comprehensive and consistent outcome measures are needed to capture the patient benefits of transitional care interventions.
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Affiliation(s)
- Natasha Tyler
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Alexander Hodkinson
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Claire Planner
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Ioannis Angelakis
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- Institute of Population Health, Department of Primary Care & Mental Health, University of Liverpool, Liverpool, United Kingdom
| | | | - Alex Hall
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | | | | | - Richard Keers
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
- Pharmacy Department, Pennine Care NHS Foundation Trust, Aston-Under-Lyne, United Kingdom
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Tom Blakeman
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Maria Panagioti
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
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Soh YY, Zhang H, Toh JJY, Li X, Wu XV. The effectiveness of tele-transitions of care interventions in high-risk older adults: A systematic review and meta-analysis. Int J Nurs Stud 2023; 139:104428. [PMID: 36682322 DOI: 10.1016/j.ijnurstu.2022.104428] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronically ill older patients are often vulnerable to detrimental health outcomes and have increased risk of preventable readmission. Tele-transitions of care interventions utilizing telecommunications and surveillance technologies help monitor patients' conditions after discharge to prevent negative health outcomes. OBJECTIVES This systematic review and meta-analysis aimed to identify and synthesize available evidence on the effectiveness of tele-transitions of care interventions on various health outcomes in older adults at high risk for readmission discharged from acute setting. METHODS Published, unpublished studies and gray literatures were identified through searching PubMed, Medline, Embase, PsycINFO, Cochrane Library, CINAHL, Scopus, ProQuest Dissertations and theses and Google Scholar from inception to December 2021. Only randomized controlled trials published in English language assessing tele-transitions of care interventions on high-risk older adults were included. Meta-analyses were performed using random-effects model in RevMan 5.4. Sensitivity and subgroup and narrative analyses were conducted. RESULTS Fourteen studies were included, of which thirteen were considered for meta-analyses. Tele-transitions of care interventions were effective in reducing readmission rate (RR = 0.59, 95%CI 0.50-0.69, z = 6.28, p < 0.00001), mortality rate (RR = 0.72, 95%CI 0.53-0.98, z = 2.12, p = 0.03), and improving health-related quality of life (SMD = 0.24, Z = 2.04, p = 0.04). However, reduction of emergency department visit (RR = 1.10, 95%CI 0.59-2.06, z = 0.31, p = 0.76) and improvement of functional status (SMD = -0.06, Z = 0.19, p = 0.85) was not observed following intervention. Subgroup analysis found that the positive effects of tele-transitions of care interventions persist up to 180 days even after the intervention. CONCLUSION This systematic review and meta-analysis concluded that tele-transitions of care interventions have promising effects on readmission, mortality rate and health-related quality of life. Tele-transitions of care interventions are cost-effective and suitable for large-scale implementation in healthcare settings. REGISTRATION The protocol was registered on PROSPERO (CRD42022295665). TWEETABLE ABSTRACT Systematic review demonstrates that monitoring older patients at high risk of readmission, following discharge from hospital, using telecommunication and surveillance technologies significantly reduces readmission and mortality rates and improves their quality of life.
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Affiliation(s)
- Yang Yue Soh
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Hui Zhang
- St Andrew's Community Hospital, 8 Simei Street 3, Singapore.
| | - Janice Jia Yun Toh
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Xianhong Li
- Xiangya School of Nursing, Central South University, 172 Tongzipo Road, Changsha, Hunan Province, People's Republic of China.
| | - Xi Vivien Wu
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; NUSMED Healthy Longevity Translational Research Programme, National University of Singapore, Singapore.
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Batista J, Pinheiro CM, Madeira C, Gomes P, Ferreira ÓR, Baixinho CL. Transitional Care Management from Emergency Services to Communities: An Action Research Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212052. [PMID: 34831807 PMCID: PMC8624079 DOI: 10.3390/ijerph182212052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022]
Abstract
In recent years, nurses have developed projects in the area of hospital to community transition. The objective of the present study was to analyze the transitional care offered to elderly people after they used emergency services and were discharged to return to the community. The action research method was chosen. The participants were nurses, elderly people 70 years old or older, and their caregivers. The study was carried out from October 2018 to August 2019. The data were collected by means of semi-structured interviews with the nurses, analysis of medical records, participatory observation, phone calls to the elderly people and caregivers, and team meetings. The qualitative data were submitted to Bardin’s content analysis. Statistical treatment was carried out by applying SPSS version 23.0. The institution’s research ethics committee approved the research. Only 31.4% of the sample experienced care continuity after discharge, and the rate of readmission to emergency services during the first 30 days after discharge was 33.4%. The referral letters lacked data on information provided to patients or caregivers, and nurses mentioned difficulties in communication between care levels, as well as obstacles to teamwork; they also mentioned that the lack of health policies and clinical rules to formalize transitional care between the hospital and the community perpetuated non-coordination of care between the two contexts. The low level of literacy of patients and their relatives are mentioned as a cause for not understanding the information regarding seeking primary health care services and handing the discharge letter. It was concluded that there is an urgent need to mobilize health teams toward action in the patients’ process of returning home, and this factor must be taken into account in care planning.
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Affiliation(s)
- José Batista
- Vila Franca de Xira Hospital, 2600-009 Vila Franca de Xira, Portugal;
- Correspondence: ; Tel.: +351-917102953
| | | | - Carla Madeira
- Vila Franca de Xira Hospital, 2600-009 Vila Franca de Xira, Portugal;
| | - Pedro Gomes
- Portuguese Institute of Oncology, Nursing Research, Innovation and Development Centre of Lisbon, 1900-160 Lisbon, Portugal;
| | - Óscar Ramos Ferreira
- Nursing School of Lisbon, Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), 1900-160 Lisbon, Portugal; (Ó.R.F.); (C.L.B.)
| | - Cristina Lavareda Baixinho
- Nursing School of Lisbon, Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), 1900-160 Lisbon, Portugal; (Ó.R.F.); (C.L.B.)
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, 2411-901 Leiria, Portugal
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Liebzeit D, Rutkowski R, Arbaje AI, Fields B, Werner NE. A scoping review of interventions for older adults transitioning from hospital to home. J Am Geriatr Soc 2021; 69:2950-2962. [PMID: 34145906 DOI: 10.1111/jgs.17323] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/05/2021] [Accepted: 05/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Older adults are at high risk for adverse outcomes as they transition from hospital to home. Transitional care interventions primarily focus on care coordination and medication management and may miss key components. The objective of this study is to examine the current scope of hospital-to-home transitional care interventions that impact health-related outcomes and to examine other key components including engagement by older adults and their caregivers. DESIGN Scoping review. METHODS Eligible articles focused on hospital transition to home intervention, measured primary outcomes posthospitalization, used randomized controlled trial designs, and included primarily adults aged 60 years and older. Articles included in this review were reviewed in full and all data were extracted that related to study objective, setting, population, sample, intervention, primary and secondary outcomes, and main results. RESULTS Five hundred sixty-seven records were identified by title. Forty-four articles were deemed eligible and included. Most common transitional care intervention components were care continuity and coordination, medication management, symptom recognition, and self-management. Few studies reported a focus on caregiver needs or goals. Common modes of intervention delivery included by phone, in person while the patient was hospitalized, and in person in the community following hospital discharge. The most common outcomes were readmission and mortality. CONCLUSION To improve outcomes beyond healthcare utilization, a paradigm shift is required in the design and study of care transition interventions. Future interventions should explore methods or novel interventions for caregiver engagement; leverage an interdisciplinary team or care coordination hub with engagement from underrepresented specialties such as social work and occupational therapy; and examine opportunities for interventions designed specifically to address older adult and caregiver-reported needs and their well-being.
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Affiliation(s)
- Daniel Liebzeit
- College of Nursing, The University of Iowa, Iowa City, Iowa, USA.,Geriatric Research, Education and Clinical Center (11G), William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| | - Rachel Rutkowski
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Alicia I Arbaje
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Beth Fields
- Department of Kinesiology, University of Wisconsin-Madison School of Education, Madison, Wisconsin, USA
| | - Nicole E Werner
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
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