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) Comparison: 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 | [31] |
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 Comparison: 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) | [32] |