Transitional care programs: who is left behind? A systematic review

Abstract

Objective: Older adults are at risk of rehospitalization if their care transitions from hospital-to-home are not properly managed. The objective of this review was to determine if older patient populations recruited for randomized controlled trials of transitional care interventions represented those at greatest risk of rehospitalization following discharge. Relevant risk factors examined were cognitive impairment, depression, polypharmacy, comorbidity, length of stay, advanced non-malignant diseases, and available social support. Design: Systematic review.Setting: Hospital to home. Participants: Older hospitalized adults.Measurements: For inclusion, articles were required to focus on hospital-to-home transitions with a self-care component, have components occurring both before and after discharge, and a randomized controlled trial design. Articles were excluded if participants had a mean age under 55 years, or if interventions focused on developmental disabilities, youth, addictions, or case management, or were solely primary-care based.Results: Following title, abstract, and full review by two authors, 17 articles met inclusion criteria. Risk factors for rehospitalization were often listed either as exclusion criteria or were not reported at baseline by the studies. One study included patients with all identified risk factors for rehospitalization.Conclusions: These data suggest that published studies of transitional care interventions do not often include older adults at highest risk of rehospitalization, raising concerns about the generalizability of their results. Studies are needed that evaluate interventions that explicitly address the needs and characteristics of these patients.

Transitional Care for Older Adults with Chronic Illnesses as a Vulnerable Population: Theoretical Framework and Future Directions in Nursing

“…A healthy transition that has received considerable attention is the move from hospital-to-home [26]. Nursing interventions for complex healthcare transitions have been examined recently [14,23,25]. The transition from having independence to requiring professional help to manage daily self-care may bring upon various types of distress and vulnerability in an individual.…”

“…The rate of hospitalization for adults over the age of 65 has shown an upward trend over the past 30 years, while rates of all other age groups have significantly declined [25]. Transitions such as the hospitalization of an older adult ultimately affect people who live within multifaceted family systems.…”

“…Older patients over the age of 75 utilize approximately 25% of all hospital encounters [25,26]. The rate of hospitalization for adults over the age of 65 has shown an upward trend over the past 30 years, while rates of all other age groups have significantly declined [25].…”

“…provision. During the discharge and home recovery transition periods, in particular, patients and family caregivers often struggle to redefine their self-concepts, resume prior roles, and employ the new knowledge and skills required to manage conditionassociated changes in health [25]. Nurses are often the primary providers of interventions that support patients and families during these vulnerable periods.…”

“…Older adults become particularly susceptible to poor outcomes when transitioning from the acute care setting because they are often discharged with ongoing care demands that exceed those that preceded the hospitalization [25,27]. Therefore, nurses should conduct transitional care according to transition phases such as hospitalization, at discharge, and after discharge.…”