Skip to main content

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    
\