Introduction: Frail older adults frequently experience transitions from hospital to home due to their complex care needs. Transitional care models (TCMs) are recommended to tackle adverse outcomes in frail patients. This review summarizes the use of integrated care components in addressing transitional care from hospital to home, provides an overview on reported outcomes and describes the impact of identified components on the outcomes hospital readmission and emergency department visit. Methods: This study is part of the European TRANS-SENIOR project. PubMed, CINAHL and Embase were searched for studies in English, German and Dutch that describe a TCM for frail older patients including both pre- and post-discharge components. Results: Seventeen studies, covering 15 TCMs were included. All TCMs describe a person-centred, tailored, pro-active and continuous transitional care service. Components like a small sized care team, intensive follow-up, shared decision making and informal caregiver involvement are likely to be associated with reduced hospital readmission and ED visits. Twenty-seven transitional care outcomes were reported: 19 service outcomes, six patient outcomes and two provider outcomes. Conclusion: Heterogeneity in content and outcomes complicates between-study comparison, yet several components were identified that improved care outcomes. Patient and provider outcomes should be included in future research.

Decreases in injury rates globally and in Europe in the past decades, although encouraging, may mask previously reported social inequalities between and within countries that persist or even increase. European research on this issue has not been systematically reviewed, which is the aim of this article. Between and within-country studies from the WHO European Region that investigate changes in social inequalities in injuries over time or in recent decades were sought in PubMed, Scopus, and Web of Science. Of the 27 studies retained, seven were cross-country and 20 were country-specific. Twelve reported changes in inequalities over time and the remaining 15 shed light on other aspects of inequalities. A substantial downward trend in injuries is reported for all causes and cause-specific ones—alongside persisting inequalities between countries and, in a majority of studies, within countries. Studies investigate diverse questions in different population groups. Depending on the social measure and injury outcome considered, many report inequalities in injuries albeit to a varying degree. Despite the downward trends in risk levels, relative social inequalities in injuries remain a persisting public health issue in the European Region.

Background Although ‘frequent flyer’ hospital admissions represent barely 3 to 8% of the total patient population in a hospital, they are responsible for a disproportionately high percentage (12 to 28%) of all admissions. Moreover, hospital admissions are an important contributor to health care costs and overpopulation in various hospitals. The aim of this research is to obtain a deeper insight into the phenomenon of frequent flyer hospital admissions. Our objectives were to understand the patients’ perspectives on the cause of their frequent hospital admissions and to identify the perceived consequences of the frequent flyer status. Methods This qualitative study took place at the University Hospital of Leuven. The COREQ guidelines were followed to provide rigor to the study. Patients were included when they had at least four overnight admissions in the past 12 months, an age above 65 years and hospital admission at the time of the study. Data were collected via semi-structured interviews and encoded in NVivo. Results Thirteen interviews were collected. A total of 17 perceived causes for frequent hospital admission were identified, which could be divided into the following six themes: patient, drugs, primary care, secondary care, home and family. Most of the causes were preventable or modifiable. The perceived consequences of being a frequent flyer were divided into the following six themes: body, daily life functioning, social participation, mental status and spiritual dimension. Negative experiences were linked to frequent flying and could be situated mainly in the categories of social participation, mental status and spiritual dimensions. Conclusions Frequent hospital admissions may be conceived as an indicator, i.e., a ‘red flag’, of patients’ situations characterized by physical, mental, spiritual and social deprivation in their home situation.

Background and Objectives Four interventions to improve care transitions between hospital and home or community settings for older adults were implemented in Leuven, Belgium over the past four years. These complex interventions consist of multiple components that challenge their implementation in practice. This study examines the influencing factors, strategies used to address challenges in implementing these interventions, and implementation outcomes from perspectives of healthcare professionals involved. Research Design and Methods This was a qualitative, collective case study which was part of the TRANS-SENIOR research network. Authors conducted semi-structured interviews with healthcare professionals about their perceptions regarding the implementation. Thematic analysis was used, and the Consolidated Framework for Implementation Research guided the final data interpretation. Results Thirteen participants were interviewed. Participants reported major implementation bottlenecks at the organizational level (resources, structure, information continuity), while facilitators were at the individual level (personal attributes, champions). They identified the overall implementation favorably, with high uptake as a key outcome. Discussion and Implications This study highlights the strong role of healthcare providers, being motivated and self-driven, to foster the implementation of interventions in transitional care in a bottom-up way. It is important to use implementation strategies targeting both the individual-level factors as well as the organizational barriers for transitional care interventions in the future.