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Table 3 Study characteristics - included studies (n = 12)

From: Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review

First author (year)

Setting, sample & study design

Stated aims

Intervention

Limitations

Discharge protocol & advanced practice nurse

Naylor (1990) [72]

US, acute inpatient (medical, surgical) to home

To test a protocol of discharge planning compared with standard hospital discharge

Protocol implemented by advanced practice nurses (APN):

Small sample size

Costs of nursing intervention was incomplete due to missing data

N = 40, average age 78.8 years

Assessment and discharge planning within 24 hours of admission

Chronic illness

Discharge plan included health teaching to be conducted in primary care

RCT

APN telephone follow up for 2 weeks post discharge

Naylor (1994) [68]

US, acute inpatient (medical, surgical) to home

To assess an APN implemented discharge planning protocol compared with standard hospital discharge

Discharge planning protocol implemented by APNs:

Generalizability of findings is limited to older people with cardiovascular diagnoses, oriented and alert at admission, well educated, with good support systems and few functional deficits

Discharge assessment 24–48 hours after hospital admission

Discharge plan developed collaboratively with client, carer, multidisciplinary team

N = 276, average age 76 years

Communication and coordination maintained by APN throughout this process with multidisciplinary team including primary care providers

Chronic illness

RCT

Post discharge APN phone availability

Naylor (1999) [77]

US, acute inpatient (medical, surgical) to home

To assess an APN implemented discharge planning protocol compared with standard hospital discharge for older people at risk of re-hospitalization

APN protocol discharge planning and home support follow up:

Generalizability of findings is limited to older people oriented and alert at admission

APN care continuity

Intervention may be limited to deployment by advanced practice nurses in primary care

APN conducted hospital discharge planning care and in home support (substituted for the visiting nurse) for the first 4 weeks post discharge

N = 363, average age 75.4 years

APN individualised patient care in collaboration with the person’s physician

Chronic illnesses

RCT

Naylor (2004) [75]

US, acute care to home

To assess the effects of an advanced practice nurse delivered transitional care intervention on older people with heart failure and comorbid conditions

Advanced practice nurse conducted a transitional care intervention emphasising

Generalizability of findings is limited to older people with exacerbation of cardiac failure and co morbid conditions

N = 239, average age 76 years

Discharge assessment

Intervention may be limited to deployment by advanced practice nurses

Discharge plan

Discharge coordination with multidisciplinary team

APN care continuity

Education

Heart failure and comorbid illnesses

Symptom management and self-management

Goal setting

Medication management

Home visits/home nursing up to 3 months following discharge

RCT

Enguidanos (2012) [74]

US, acute care to home

To assess impact of brief nurse practitioner (NP) intervention for older people discharged from hospital to home compared with standard hospital discharge

NP in primary care conducted:

Sample size insufficiently powered to detect an effect of the intervention

Education about discharge instructions to older person

Intervention may be limited to deployment by nurse practitioners

N = 199, average age 73.58 years

Medication reconciliation

Home care needs assessment and referral to resources

Scheduling follow-up medical appointments

Chronic illnesses

RCT

General practitioner and primary care nurse models

Weinberger (1996) [67]

US, acute care to home

To test an primary care intervention on rates of re-hospitalization, length of stay, quality of life and veteran satisfaction compared with standard discharge care

Before discharge:

Generalizability of study limited to older US male veterans

The primary care nurse conducted the discharge assessment, provided education and the contact telephone numbers of the primary care nurse and general practitioner (GP), and scheduled an appointment within 2 days of discharge to attend the primary care clinic

Substantial primary care resources were required to implement the intervention

N = 1396, average age 63 years, veteran sample, mostly male (98.5%)

The GP visited the veteran in hospital within 2 days prior to discharge and reviewed the discharge plan, medication, and medical problems with the hospital physicians

Chronic illnesses

After discharge:

The primary care nurse telephoned the patient (within 2 working days of discharge) at home to assess any difficulties with medications/medical treatments, health problems, remind of follow-up appointment

Patients were followed-up in clinic

The primary care nurse and GP reviewed treatment plan at first appointment.

RCT

McInnes (1999) [73]

Australia, acute hospital-geriatric care unit (patients admitted under care of geriatrician) to home

To test if GP involvement in discharge planning patient outcomes when compared with standard hospital discharge

Standard hospital discharge practice with the addition of GP visit pre discharge:

Of those randomized to the intervention group only 52% of patients were actually visited by their GP in hospital

GPs invited to undertake pre discharge visit:

N = 364, average age 81 years

Substantial primary care resources were required

Information sought from GP re recommendations for post discharge care

RCT

GP able to discuss care/treatment with hospital based medical and allied

health staff

GP had access to the patient’s hospital care record during the visit

Preen (2005) [66]

Australia, acute hospital to home

To test a hospital coordinated discharge plan that involved the GP when compared with standard hospital discharge

Research nurse based in the hospital:

Intervention was not fully implemented as only 42% of GPs returned the discharge plan to the hospital prior to discharge

Developed discharge plan (determined client discharge problems, goals and community service provider involvement)

Sample size may have been insufficiently powered to detect an effect of the intervention

Faxed the discharge plan to the GP 24–48 hours prior to discharge

N = 189, average age 75 years

The GP

Reviewed the discharge plan, modified it and returned it to the hospital by fax

Chronic illnesses

Research nurse based in the hospital:

Explained the discharge plan to the client

RCT

Provided copies of the discharge plan to the client, and all service providers identified on the care plan.

Scheduled an appointment with the GP

Self-management and transition coaching

Coleman (2006) [69]

US, acute hospital to home

To assess the effects of a care transitions intervention in comparison with standard hospital discharge care, using RCT design, on rehospitalisation rates for older people

Care Transitions Intervention (as per Coleman et al. 2004 above) Intervention developed from qualitative research with older people and their care givers about what would be most valuable to them during care transitions:

Intervention may be limited to deployment by advanced practice nurses in the role of transition coach

N = 747, average age 76 years

Medication assistance and self-management

Chronic illnesses

Patient centred and owned record

Timely follow-up from primary care providers

RCT

List of problem triggers indicating deterioration in their particular chronic illness and what to do about these

Discharge case management

Lim (2003) [76]

Australia, acute hospital to home

To test the effects of case management and post acute care services on organisation and patient/caregiver outcomes in comparison with standard hospital discharge

Post Acute Care program:

Costs were averages of community services and daily hospital bed utilisation rates, actual costs for each individual were not captured

Short term case management and provision of post-acute care services (in home) nursing, allied health, community supports

N = 598, average age 76 years

Chronic illnesses

RCT

Inpatient geriatric evaluation, co-management (with ward staff) and transitional care

Hansen (1995) [70]

Denmark, subacute geriatric ward to home

To compare the intervention with standard hospital discharge on the number of medical and social problems after discharge, the need for modification of the discharge plan after discharge and rates of re-hospitalization to hospital

The Geriatric Evaluation and Management team (geriatrician, nurse and physical therapist) supported inpatient discharge planning and follow-up at home

Generalizability of findings limited to older people with low functioning

N = 193, average age intervention 78 to 80 years

Intervention may be limited to deployment by geriatricians

Follow-up involved re-evaluation and modification of the care plan, communication with the primary care team (GP, community nurse) during home visits at 1, 3, 8, 16 weeks following discharge

Multiple chronic conditions and low functional status

RCT

Legrain (2011) [71]

France, acute inpatient geriatric care unit to varying locations: home, nursing home, rehabilitation unit, acute care unit

To compare a comprehensive discharge intervention with standard hospital discharge on emergency department visits and re-hospitalisations

Geriatrician delivered inpatient intervention:

Findings generalizable to functionally dependent older people

Medication review

Education re self-management of disease

Communication principally with GP

Intervention may be limited to deployment by geriatricians

Screening for main risks for frail elderly

Depression

N = 665, average age 86 years

Chronic illnesses

 

RCT

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