The impact of transitional care programs on health services utilization in community-dwelling older adults: a systematic review

Abstract

Based on a review of 23 studies conducted in the USA, Hong Kong, Canada, Germany, the Netherlands, Sweden and Switzerland, we identified four major conclusions. First, transitional care reduces rehospitalization rates over time, with the largest effects seen at 30 days. Second, transitional care may increase the utilization of primary care services and thus have a favourable impact on preventative care. Third, transitional care may reduce home health usage. Fourth, transitional care interventions of one month or less appear to be as effective as longer interventions in reducing hospital usage.

Study protocol for a hospital-to-home transitional care intervention for older adults with multiple chronic conditions and depressive symptoms: a pragmatic effectiveness-implementation trial

“…There is very little evidence regarding why certain transitional care interventions work in some settings or contexts but not in others [ 76 ]. This approach enables a focus on the complexity of interactions among the many contextual, macro-level factors that can affect implementation, which have been noted as highly relevant in determining both the outcomes and scalability of transitional care interventions [ 8 , 28 , 29 ]. Second, the study will include a cost analysis from a societal perspective – an outcome that has been overlooked in previous transitional care studies.…”

“…This is an inherent limitation of pragmatic trials [ 78 , 79 ], and is also a common challenge associated with transitional care evaluations. Variation in the nature and scope of interventions across settings has led authors of multiple systematic reviews to qualify their conclusions about the efficacy of transitional care models [ 27 – 29 , 35 ]. Close monitoring throughout the duration of the study will assist the investigators in determining any adaptations that need to be made to the intervention.…”

“…Although these Transitional Care Interventions have been linked to several positive outcomes, including decreasing hospital readmissions, the effectiveness of these interventions for older adults with MCC and depressive symptoms is uncertain. Most trials assessing the impact of transitional care interventions have excluded older adults with MCC, omitted mental health considerations such as depressive symptoms, provide little information on cost and implementation strategies, and used weak study designs [ 26 – 29 ]. Most of these studies have focused on acute care readmission rates as the primary measure of effect for many transitional care interventions, with limited attention to patient-relevant outcomes, such as health-related quality of life.…”

Atividades do enfermeiro na transição do cuidado: realidades e desafios

“…1 Studies have shown that there are often adverse events after discharge, as medication errors, use of emergency services and hospital readmissions. [2][3] Thus, efforts are necessary to ensure care continuity at home.…”

“…4 This is an important strategy to ensure the integral care during hospitalization and after hospital discharge, increasing the use of primary care services and reducing hospital readmissions. [3][4][5][6] The literature shows that the nurse has been one of the professionals most involved in care transition from the hospital to the domicile, developing activities in the care planning for discharge, aid for social rehabilitation, health education, articulation with other health services and post-discharge follow-up. [7][8][9] The nurse allows hospitalization to become a moment of learning, with an exchange of knowledge among patient, family and healthcare professional.…”