Stakeholder involvement in care transition planning for older adults and the factors guiding their decision-making: a scoping review

Abstract

ObjectiveTo synthesise the existing literature on care transition planning from the perspectives of older adults, caregivers and health professionals and to identify the factors that may influence these stakeholders’ transition decision-making processes.DesignA scoping review guided by Arksey and O’Malley’s six-step framework. A comprehensive search strategy was conducted on 7 January 2021 to identify articles in five databases (MEDLINE, Embase, CINAHL Plus, PsycINFO and AgeLine). Records were included when they described care transition planning in an institutional setting from the perspectives of the care triad (older adults, caregivers and health professionals). No date or study design restrictions were imposed.SettingThis review explored care transitions involving older adults from an institutional care setting to any other institutional or non-institutional care setting. Institutional care settings include communal facilities where individuals dwell for short or extended periods of time and have access to healthcare services.ParticipantsOlder adults (aged 65 or older), caregivers and health professionals.Results39 records were included. Stakeholder involvement in transition planning varied across the studies. Transition decisions were largely made by health professionals, with limited or unclear involvement from older adults and caregivers. Seven factors appeared to guide transition planning across the stakeholder groups: (a) institutional priorities and requirements; (b) resources; (c) knowledge; (d) risk; (e) group structure and dynamic; (f) health and support needs; and (g) personality preferences and beliefs. Factors were described at microlevels, mesolevels and macrolevels.ConclusionsThis review explored stakeholder involvement in transition planning and identified seven factors that appear to influence transition decision-making. These factors may be useful in advancing the delivery of person and family-centred care by determining how individual-level, group-level and system-level values guide decision-making. Further research is needed to understand how various stakeholder groups balance these factors during transition planning in different health contexts.

Understanding the Goals of Older Adults with Complex Care Needs, Their Family Caregivers and Their Care Providers Enrolled in a Patient Navigation Program

“…All participant types (i.e., older adults, caregivers and HCPs) noted that finding someone to consistently rely on for support was important in managing complex needs in community settings. Similar findings were reported in other papers exploring the needs and goals of care for these participant types during transitions in care (Carbone et al, 2022; Kuluski et al, 2019). PNPs might provide an opportunity for care teams to communicate shared goals, enlist support for supporting those goals, and advocate for these goals within clinical teams.…”

“…As such, healthcare policymakers and personnel should make a concentrated effort to tailor healthcare that is attuned to older adults’ preferences’ for balancing safety risks in favor of independence (Lawrence & Murray, 2010). Moreover, as aligned with previous research, older adults with high levels of medical complexity tend to have different goals than their families and HCP (Carbone et al, 2022). PN programs should consider integrating a goals-of-care discussion that helps to ensure the older adult, care team and family are on the same page, such as through a care conference or through electronic tools designed to support goal-oriented healthcare delivery such as the Patient Report Outcome (ePRO) tool, which encourages patients and providers to collaboratively develop healthcare goals using an application (Steele Gray et al, 2016).…”

Understanding the Goals of Older Adults with Complex Care Needs, Their Family Caregivers and Their Care Providers Enrolled in a Patient Navigation Program

“…All participant types (i.e., older adults, caregivers and HCPs) noted that finding someone to consistently rely on for support was important in managing complex needs in community settings. Similar findings were reported in other papers exploring the needs and goals of care for these participant types during transitions in care (Carbone et al, 2022; Kuluski et al, 2019). PNPs might provide an opportunity for care teams to communicate shared goals, enlist support for supporting those goals, and advocate for these goals within clinical teams.…”

“…As such, healthcare policymakers and personnel should make a concentrated effort to tailor healthcare that is attuned to older adults’ preferences’ for balancing safety risks in favor of independence (Lawrence & Murray, 2010). Moreover, as aligned with previous research, older adults with high levels of medical complexity tend to have different goals than their families and HCP (Carbone et al, 2022). PN programs should consider integrating a goals-of-care discussion that helps to ensure the older adult, care team and family are on the same page, such as through a care conference or through electronic tools designed to support goal-oriented healthcare delivery such as the Patient Report Outcome (ePRO) tool, which encourages patients and providers to collaboratively develop healthcare goals using an application (Steele Gray et al, 2016).…”

Caregivers’ Role in In-Home Video Telehealth: National Survey of Occupational Therapy Practitioners

“…This aligns with evidence in which caregivers report that being involved in patients' video visits helps them get their own questions answered [36]. It also underscores the potential for caregiver contribution in video telehealth to enhance decision-making around care transitions, an important facet of older adult care [66,67]. Findings also reveal potential challenges to caregiver involvement in video sessions, particularly among rural populations.…”

Transitional care decision‐making through the eyes of older people and informal caregivers: An in‐depth interview‐based study

“…Apart from information, respondents in our study stressed the need for practical and/or emotional support in the decision‐making process. This finding is mirrored in two recent reviews of the literature 9,26 that underline the importance of family support for informal caregivers and the informal caregivers' support for their loved ones during care transitions. Our study adds the importance of informal caregivers' wishes for timelier multidisciplinary follow‐up and guidance in transitional care decision‐making.…”

Understanding the Goals of Older Adults with Complex Care Needs, Their Family Caregivers and Their Care Providers Enrolled in a Patient Navigation Program

“…All participant types (i.e., older adults, caregivers and HCPs) noted that finding someone to consistently rely on for support was important in managing complex needs in community settings. Similar findings were reported in other papers exploring the needs and goals of care for these participant types during transitions in care (Carbone et al, 2022; Kuluski et al, 2019). PNPs might provide an opportunity for care teams to communicate shared goals, enlist support for supporting those goals, and advocate for these goals within clinical teams.…”

“…As such, healthcare policymakers and personnel should make a concentrated effort to tailor healthcare that is attuned to older adults’ preferences’ for balancing safety risks in favor of independence (Lawrence & Murray, 2010). Moreover, as aligned with previous research, older adults with high levels of medical complexity tend to have different goals than their families and HCP (Carbone et al, 2022). PN programs should consider integrating a goals-of-care discussion that helps to ensure the older adult, care team and family are on the same page, such as through a care conference or through electronic tools designed to support goal-oriented healthcare delivery such as the Patient Report Outcome (ePRO) tool, which encourages patients and providers to collaboratively develop healthcare goals using an application (Steele Gray et al, 2016).…”

Caregivers’ Role in In-Home Video Telehealth: National Survey of Occupational Therapy Practitioners

“…This aligns with evidence in which caregivers report that being involved in patients' video visits helps them get their own questions answered [36]. It also underscores the potential for caregiver contribution in video telehealth to enhance decision-making around care transitions, an important facet of older adult care [66,67]. Findings also reveal potential challenges to caregiver involvement in video sessions, particularly among rural populations.…”

Transitional care decision‐making through the eyes of older people and informal caregivers: An in‐depth interview‐based study

“…Apart from information, respondents in our study stressed the need for practical and/or emotional support in the decision‐making process. This finding is mirrored in two recent reviews of the literature 9,26 that underline the importance of family support for informal caregivers and the informal caregivers' support for their loved ones during care transitions. Our study adds the importance of informal caregivers' wishes for timelier multidisciplinary follow‐up and guidance in transitional care decision‐making.…”

Understanding the Goals of Older Adults with Complex Care Needs, Their Family Caregivers and Their Care Providers Enrolled in a Patient Navigation Program

“…All participant types (i.e., older adults, caregivers and HCPs) noted that finding someone to consistently rely on for support was important in managing complex needs in community settings. Similar findings were reported in other papers exploring the needs and goals of care for these participant types during transitions in care (Carbone et al, 2022; Kuluski et al, 2019). PNPs might provide an opportunity for care teams to communicate shared goals, enlist support for supporting those goals, and advocate for these goals within clinical teams.…”

“…As such, healthcare policymakers and personnel should make a concentrated effort to tailor healthcare that is attuned to older adults’ preferences’ for balancing safety risks in favor of independence (Lawrence & Murray, 2010). Moreover, as aligned with previous research, older adults with high levels of medical complexity tend to have different goals than their families and HCP (Carbone et al, 2022). PN programs should consider integrating a goals-of-care discussion that helps to ensure the older adult, care team and family are on the same page, such as through a care conference or through electronic tools designed to support goal-oriented healthcare delivery such as the Patient Report Outcome (ePRO) tool, which encourages patients and providers to collaboratively develop healthcare goals using an application (Steele Gray et al, 2016).…”

Caregivers’ Role in In-Home Video Telehealth: National Survey of Occupational Therapy Practitioners

“…This aligns with evidence in which caregivers report that being involved in patients' video visits helps them get their own questions answered [36]. It also underscores the potential for caregiver contribution in video telehealth to enhance decision-making around care transitions, an important facet of older adult care [66,67]. Findings also reveal potential challenges to caregiver involvement in video sessions, particularly among rural populations.…”

Transitional care decision‐making through the eyes of older people and informal caregivers: An in‐depth interview‐based study

“…Apart from information, respondents in our study stressed the need for practical and/or emotional support in the decision‐making process. This finding is mirrored in two recent reviews of the literature 9,26 that underline the importance of family support for informal caregivers and the informal caregivers' support for their loved ones during care transitions. Our study adds the importance of informal caregivers' wishes for timelier multidisciplinary follow‐up and guidance in transitional care decision‐making.…”