Background Care transitions of older persons between multiple care settings are frequently hampered by various issues such as discontinuous care delivery or poor information transfer among healthcare providers. Therefore, several innovations have been developed to optimize transitional care (TC). This review aims to identify which factors influence the implementation of TC innovations. Methods As part of TRANS-SENIOR, an international innovative training and research network focusing on enhancing or avoiding care transitions, a scoping review was conducted. The five stages of the Arksey and O’Malley framework were followed. PubMed/MEDLINE, EMBASE, and CINAHL were searched, and eligible studies published between years 2000 and 2020 were retrieved. Data were extracted from the included studies and mapped to the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) and Care Transitions Framework (CTF). Results Of 1537 studies identified, 21 were included. Twenty different TC innovations were covered and aimed at improving or preventing transitions between multiple care settings, the majority focused on transitions from hospital to home. Key components of the innovations encompassed transition nurses, teach-back methods, follow-up home visits, partnerships with community services, and transfer units. Twenty-five prominent implementation factors (seven barriers, seven facilitators, and eleven factors with equivalent hindering/facilitating influence) were shown to affect the implementation of TC innovations. Low organizational readiness for implementation and the overall implementation climate were topmost hindering factors. Similarly, failing to target the right population group was commonly reported as a major barrier. Moreover, the presence of skilled users but with restricted knowledge and mixed attitudes about the innovation impeded its implementation. Among the eminent enabling factors, a high-perceived advantage of the innovation by staff, along with encouraging transition roles, and a continuous monitoring process facilitated the implementation of several innovations. Other important factors were a high degree of organizational networks, engaging activities, and culture; these factors had an almost equivalent hindering/facilitating influence. Conclusions Addressing the right target population and instituting transition roles in care settings appear to be specific factors to consider during the implementation of TC innovations. Long-term care settings should simultaneously emphasize their organizational readiness for implementation and change, in order to improve transitional care through innovations.

The transition from home to a nursing home can be stressful and traumatic for both older persons and informal caregivers and is often associated with negative outcomes. Additionally, transitional care interventions often lack a comprehensive approach, possibly leading to fragmented care. To avoid this fragmentation and to optimize transitional care, a comprehensive and theory-based model is fundamental. It should include the needs of both older persons and informal caregivers. Therefore, this study, conducted within the European TRANS-SENIOR research consortium, proposes a model to optimize the transition from home to a nursing home, based on the experiences of older persons and informal caregivers. These experiences were captured by conducting a literature review with relevant literature retrieved from the databases CINAHL and PubMed. Studies were included if older persons and/or informal caregivers identified the experiences, needs, barriers, or facilitators during the transition from home to a nursing home. Subsequently, the data extracted from the included studies were mapped to the different stages of transition (pre-transition, mid-transition, and post-transition), creating the TRANSCITmodel. Finally, results were discussed with an expert panel, leading to a final proposed TRANSCIT model.The TRANSCIT model identified that older people and informal caregivers expressed an overall need for partnership during the transition from home to a nursing home. Moreover, it identified 4 key components throughout the transition trajectory (ie, pre-, mid-, and post-transition): (1) support, (2) communication, (3) information, and (4) time.The TRANSCIT model could advise policy makers, practitioners, and researchers on the development and evaluation of (future) transitional care interventions. It can be a guideline reckoning the needs of older people and their informal caregivers, emphasizing the need for a partnership, consequently reducing fragmentation in transitional care and optimizing the transition from home to a nursing home.

Background and Objectives The transition from home to a nursing home is a stressful event for both older persons and informal caregivers. Currently, this transition process is often fragmented, which can create a vicious cycle of healthcare-related events. Knowledge of existing care interventions can prevent or break this cycle. This project aims to summarize existing interventions for improving transitional care, identifying their effectiveness and key components. Research Design and Methods A scoping review was performed within the European TRANS-SENIOR consortium. The databases PubMed, EMBASE, PsycINFO, Medline, and CINAHL were searched. Studies were included if they described interventions designed to improve the transition from home to a nursing home. Results 17 studies were identified, describing 13 interventions. The majority of these interventions focused on nursing home adjustment with one study including the entire transition pathway. The study identified eight multi- and five single-component interventions. From the multi-component interventions, seven main components were identified: education, relationships/communication, improving emotional well-being, personalized care, continuity of care, support provision, and ad hoc counseling. The study outcomes were heterogeneous, making them difficult to compare. The study outcomes varied, with studies often reporting nonsignificant changes for the main outcome measures. Discussion and Implications There is a mismatch between theory on optimal transitional care and current transitional care interventions, as they often lack a comprehensive approach. This research is the first step towards a uniform definition of optimal transitional care and a tool to improve/develop (future) transitional care initiatives on the pathway from home to a nursing home.

Background The transition from home to a nursing home is a common care process experienced by older persons with dementia and their informal caregivers. This transition process is often experienced as fragmented and is paired with negative outcomes for both older persons (e.g. mortality) and informal caregivers (e.g. grief). Due to the central role that informal caregivers play, it is crucial to capture their experiences throughout all phases of the transition. Methods A secondary data analysis was conducted using an interpretative phenomenological design. A total of 24 informal caregivers of older persons with dementia, moving to a nursing home, participated in in-depth interviews. Data were collected between February 2018 and July 2018 in the Netherlands. Data were analysed using Interpretative Phenomenological Analysis. Results The transition experiences are characterised by three paradoxes: (i) contradicting emotions during the transition process; (ii) the need for a timely transition versus the need to postpone the transition process and (iii) the need for involvement versus the need for distance. All paradoxes are influenced by the healthcare system. Conclusions The identified paradoxes show the impact of the healthcare system and the importance of timely planning/preparing for this transition on the experiences of informal caregivers. In addition, it provides healthcare professionals insight into the thought processes of informal caregivers. Future research can use these paradoxes as a foundation to develop innovations aiming to improve the transition process from home to a nursing home for informal caregivers and, consequently, older persons.

The transition from home to a nursing home is a complex process, existing of three transition phases (pre-, mid- and post-transition). It is often fragmented, leading to negative outcomes for older persons and informal caregivers. To prevent these negative outcomes, knowledge of existing transitional care interventions is paramount. Therefore, a scoping review was performed, summarizing current interventions aiming to improve transitional care. The review identified 17 studies, describing eight multi- and five single-component interventions. From the multi-component interventions, seven main components were identified: education, relationships/communication, improving emotional well-being, personalized care, continuity of care, support provision, and ad hoc counseling. This review identified a clear mismatch between theory on optimal transitional care and current transitional care interventions. All interventions focused on either a specific phase or target population throughout the transition process. This inhibits a continuous transition process in which a partnership between all stakeholders involved exists.

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The transition from home to a nursing home is a complex and emotional process, especially for older persons with dementia. The informal caregiver usually plays a central role in this care process, which is often fragmented. Therefore, this study aims to analyze the experiences of informal caregivers of older persons with dementia during this transition.An interpretative phenomenological design was used to analyze secondary data. In-depth interviews were conducted with informal caregivers, in the Netherlands, between February 2018 and July 2018. The study identified three, interwoven paradoxes influenced by the healthcare system and the healthcare professionals providing care. The first paradox described the initial negative emotions related to a nursing home move. Those emotions are a paradox to the feelings of relief and acceptance later in the transition process. The second paradox was related to a prospective need to postpone the transition for as long as possible and a retrospective need for a timely transition plan. The third paradox defines an internal struggle for the informal caregivers of wanting to remain involved while simultaneously experiencing a need for distance from care responsibilities. This study identifies a fine line between optimal and fragmented transitional care. The results can motivate informal caregivers to start planning the move. Similarly, it allows healthcare professionals to provide tailored support. Future research should focus on defining these paradoxes and their link with the healthcare system to determine if the transition from home to a nursing home can be optimized.