Continuity, Coordination, and Transitions of Care for Patients with Serious and Advanced Illness: A Systematic Review of Interventions

Abstract

Many studies were limited by methodologic issues such as use of measurement tools not developed for patients with advanced disease and small sample size. Interventions and outcomes were too heterogeneous for meta-analysis. We found moderate evidence that interventions targeting continuity, coordination, and transitions in patients with advanced and serious illness improve patient and caregiver satisfaction, but low evidence for other outcomes. Further research is needed on how to target these domains for outcomes such as health care utilization.

The Effectiveness of a Care Transitions and Rapid Response Nurse Intervention at Reducing Readmissions and Emergency Department Use for High Risk Patients

“…Given the frailty of the population, this was probably not sufficient. Many transitional interventions have longer periods of follow-up and have demonstrated longer-term success in changing health status and health utilization behaviours of the population they serve [44,45]. Naylor et al [46] suggests that although transition interventions are successful in improving the patient's self-management capacity, there is a need for on-going follow-up in the post-discharge period given the on-going progressive nature of the chronic conditions of patients and in the case of this particular study, increasing levels of frailty.…”

Quality Palliative Care and the First Domain

“…12 A systematic review of interventions in the literature evaluated continuity, coordination, and transitions of care as key components of PC care. 13 Within these domains, they searched for improvement in patient and caregiver quality of life, satisfaction, and health care utilization outcomes for those with advanced or serious illness. The specific interventions or metrics were too heterogeneous for a meta-analysis.…”

“…Improvement in utilization was low. 13 Investigators in the first benchmarking study to look at quality PC in the United States compared the delivery of PC and key essential elements of PC in 35 hospitals across academic settings. 14 This retrospective chart review included persons who received and did not receive a PC consult.…”

Maintenance of continuity of care in a rotating-physician model in an outpatient palliative care clinic

“…[5]. COC for patients with serious illnesses has long been regarded as important, with attention paid to many facets of continuity, including both personal or relational continuity as well as informational/knowledge continuity [6,7]. Studies from family practice as well as home-based palliative care indicate the importance of COC for patients [8,9,10,11].…”