Skip to main content

Table 3 Patient navigator interventions with a focus on transitional care

From: The role of patient navigators in ambulatory care: overview of systematic reviews

Skill-mix interventions Outcomes
Details of the intervention Profession(s) Population Countries Patient-related outcomes Health-system related outcomes Source
Patient navigation in transitional care (e.g. discharge planning, coordination of care, phone support, home visits, liaison with medical and community services, patient/caregiver education) Intervention:
Registered nurse with advanced practice expertise, gerontological advanced practice nurse, social worker; physicians and physician mentors (supporter in a multidisciplinary team)
Not reported
Older patients with chronic diseases AU, CA, US • Improved depression symptoms
• Improvement for disease self- management
• Improved quality of life
• Improved activities of daily living, communication with patients, caregivers, education for caregivers, self-management, knowledge of patient medication
• Lower readmissions
• Shorter time to readmission and less hospital days
• Improved community referrals
• Inconclusive effect on costs related to use of emergency rooms
Transitional care interventions from hospital to home (majority of interventions focused on contacts, home visits and educational components; others included multidisciplinary coordination and collaborations) Intervention:
Nurses, primary care physicians, cardiologists, pharmacist
Family physician, not consistently reported
Older patients with at least one chronic disease AT, AU, CA, BE, CH, CN, DE, DK, ES, FI, HK, IR, IT, JP, NL, NZ, SE, SI, UK • Mortality: Significantly lower for intervention (RD − 0.02, − 0.05-0.00, NNT 50) and maintained at 6, 12 and 18 months post-discharge
• No significant effect on quality of life
• Significantly fewer ED visits at 3 months post-discharge (Risk Difference (RD) -0.08, − 0.15, − 0.01); no effect at 1, 6, 12 months
• Total readmission days: Significant difference at 3 months (MD − 1.33, − 2.15, − 0.52), 6 months (MD − 1.42, − 2.33, − 0.50), 12 months (MD − 3.37, − 5.21, − 1.53), 18 months (MD − 3.16, − 5.68, − 0.64); no difference at 1 month
• Risk hospital admission: Significantly lower at 6 months (RD − 0.05, − 0.09, − 0.00), 12 months (RD − 0.11, − 0.17, − 0.05), and at 24 months (MD − 1.03, − 1.81, − 0.24)
  1. CI Confidence Interval, ED Emergency Department, MD Mean Difference, OR Odds Ratio, p p-value, RD Risk Difference, Country abbreviations: AU Australia, AT Austria, BE Belgium, CA Canada, CH Switzerland, CN China, DE Germany, DK Denmark, ES Spain, FI Finland, HK Hoch Kong, IR Iran, IT Italy, JP Japan, NL The Netherlands, NZ New Zealand, SE Sweden, SI Slovenia, UK United Kingdom, US United States of America