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Table 4 Main findings - 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)

Main findings

Discharge protocol & advanced practice nurse

Naylor (1990) [72]

Significant reduction in rates of re-hospitalization for intervention group over the 12 weeks post discharge

No difference in length of stay

No difference in posthospital infections

Naylor (1994) [68]

Intervention patients in the medical units at 6 week follow-up experienced:

Significant delay in re-hospitalization to hospital

Fewer total days of re-hospitalisation

Lower health care costs (inclusive of inpatient, clinic, home visits)

No change in functional status, mental status, self-esteem or affect

Intervention caregivers up to 12 weeks following discharge experienced:

No change in functional status, caregiving demands, family

functioning, affect

Naylor (1999) [77]

Intervention group at 24 week follow-up experienced fewer:

Re-hospitalizations

Hospital days per patient

Lower costs than control group

No statistically significant differences in functional status, depression or patient satisfaction between groups

Naylor (2004) [75]

The time to first admission was longer in intervention patients

At 52 weeks, intervention patients had fewer re-hospitalizations and lower total mean costs

There were short term improvements among intervention patients in quality of life (physical domain, up to 12 weeks post discharge) and satisfaction with discharge and transition care (up to 6 weeks post discharge)

Enguidanos (2012) [74]

No change in re-hospitalization rates at 6 months following enrolment in the study

The intervention group experienced significantly fewer visits to GPs

There were no changes between intervention and control groups in self-efficacy or satisfaction with service

General practitioner and primary care nurse models

Weinberger (1996) [67]

At 6 months following discharge:

Intervention group had significantly higher rates of re-hospitalization and if re-admitted longer in hospital stay than controls (discharge as usual).

Intervention group were significantly more satisfied with their care than controls

No differences in quality of life scores between groups

Quality of life scores were low in both groups

McInnes (1999) [73]

At 6, 12, 26 weeks following discharge:

No significant differences in length of stay, rates of re-hospitalization or time to first re-hospitalization

Intervention patients were significantly more likely to be

Referred to community services at discharge and report that hospital staff had discussed their discharge plan with them

Intervention patients reported increased satisfaction with discharge arrangements and preparation

Preen (2005) [66]

There were no differences in length of stay between groups

One week following discharge:

GPs in the intervention group were more satisfied with the documentation

Discharge communication to GPs in the intervention was significantly faster than for GPs in the control group

Patients in the intervention group reported improved satisfaction with discharge planning, access to health services, confidence with discharge, and mental quality of life

Self-management and transition coaching

Coleman (2006) [69]

Intervention group had significantly lower re-hospitalization rates than the control group at 30, 90 and 180 days post discharge

Intervention group had significantly lower hospital costs than the control group at 30, 90 and 180 days post discharge

Discharge case management

Lim (2003) [76]

Over 6 month follow-up period there were no differences in rates of unplanned re-hospitalizations

Intervention patients had significantly reduced length of stay (index hospitalisation)

Costs (hospital utilisation) lower in intervention patients over 6

months following discharge

No differences in costs (utilisation of community services)

between groups

Significantly improved self-reported quality of life in intervention patients at one month follow-up

No difference in caregiver burden at 1 month follow-up

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

Hansen (1995) [70]

At 6 months following discharge:

People in the intervention group were significantly less likely to be re-admitted to hospital than those in the control group

There were no differences in rates of admission to nursing homes or mortality rates

Significant increase in new and unforseen problems identified following discharge in people receiving the intervention.

Intervention participants were significantly more likely to be allocated home help.

Legrain (2011) [71]

Older people in the intervention group were significantly less likely to attend the emergency department or be re-admitted at 3 months following discharge

 

There were no differences between groups in ED attendances or re-hospitalizations at 6 months following discharge