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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
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