Sarzynski et al., 2019(77. Sarzynski E, Ensberg M, Parkinson A, Fitzpatrick L, Houdeshell L, Given C, et al. Eliciting nurses' perspectives to improve health information exchange between hospital and home health care. Geriatr Nurs. 2019;40(3):277-83.)
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USA, Mid-Michigan Qualitative study; focal group |
Home care nurses (n=19) |
Implementation of protocols for medication adjustment before the first outpatient follow-up appointment. Simplification of the medication regimen. Health guidance using materials with simple language; Screening for social determinants of health (financial, transport and home environment); Identification of caregiver and their contact information |
Kim et al., 2020(88. Kim YS, Lee J, Moon Y, Kim HJ, Shin J, Park JM, et al. Development of a senior-specific, citizen-oriented healthcare service system in South Korea based on the Canadian 48/6 model of care. BMC Geriatr. 2020;20(1):32.)
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South Korea Focus group interview and expert consultation |
Nurses and doctors |
Geriatric Screening for Care-10 screening and assessment, covering ten domains: Cognitive impairment, depression, delirium, polypharmacy, functional decline, dysphagia, malnutrition, urinary and fecal incontinence, pain. |
Cheen et al., 2017(99. Cheen MH, Goon CP, Ong WC, Lim PS, Wan CN, Leong MY, et al. Evaluation of a care transition program with pharmacist-provided home-based medication review for elderly Singaporeans at high risk of readmissions. Int J Qual Health Care. 2017;29(2):200-5.)
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Singapore Retrospective observational study |
Nurse care coordinators and pharmacists |
Home visits by pharmacists and care and/or care coordinators (nurses) to provide information on disease management, comprehensive review and medication advice. |
Hansen et al., 2021(1010. Hansen TK, Pedersen LH, Shahla S, Damsgaard EM, Bruun JM, Gregersen M. Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial. Arch Gerontol Geriatr. 2021;97:104511.)
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Denmark Randomized controlled study |
Nurses supported by a general practitioner |
Comprehensive geriatric assessment based on the 14 components of nursing according to Virginia Henderson’s theory. Review of the prescription list. |
Wang et al., 2019(1111. Wang YC, Lu YP, Wang JH, Liang CK, Choul MY, Lin YT. The Effectiveness of a Timely Discharge Plan in Older Adults: A Prospective Hospital-Based Cohort Study in Southern Taiwan. Aging Med Healthcare. 2019;10(3):104-8.)
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Thailand Prospective case-control study |
Discharge specialist nurses, geriatricians and physiotherapists |
Comprehensive geriatric patient assessment prior to hospital discharge by specialist discharge nurses. Promoting long-term care at home, communicating with providers before the patient is discharged. |
Allen et al., 2020(1212. Allen J, Hutchinson AM, Brown R, Livingston PM. Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners' Perspectives. Int J Integr Care. 2020;20(2):1-10.)
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Australia Qualitative study |
Multi team, mostly composed of nurses (n=25) |
Discussion between multidisciplinary teams for a quick and safe transition. Preparation of a hospital discharge plan for the home environment; Involvement of patients and caregivers in transitional care. |
Costa et al., 2019(1313. Costa MF, Andrade SR, Soares CF, Pérez EI, Tomás SC, Bernardino E. The continuity of hospital nursing care for Primary Health Care in Spain. Rev Esc Enferm USP. 2019;53:e03477.)
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Spain Qualitative study |
Hospital liaison nurses (n=19) |
Assessment and verification of the need for care through consultation with the multidisciplinary team and interdisciplinary meeting. Assessment of patients before hospital discharge, including physical, cognitive, mental, social and emotional domains; Use of instruments such as Gordon, Barthel, Pfeiffer and Zarit to assess complex care (wounds), nutritional status and information about the caregiver. Social assessment; Application of a social risk questionnaire (TIRS). |
Verweij et al., 2018(1414. Verweij L, Jepma P, Buurman BM, Latour CH, Engelbert RH, Ter Riet G, et al. The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality. BMC Health Serv Res. 2018;18(1):508.)
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Netherlands Single-blind multicenter study with randomization |
Nurses specializing in cardiology, geriatrics and community care and a physiotherapist |
Discharge planning and preparation of care plans based on comprehensive geriatric assessment, current health condition and medication prescription. Primary care physiotherapist employment for cardiac rehabilitation at home before hospital discharge. Checking medications used at home and prescribed upon hospital discharge. |
Arbaje et al., 2010(1515. Arbaje AI, Maron DD, Yu Q, Wendel VI, Tanner E, Boult C, et al. The geriatric floating interdisciplinary transition team. J Am Geriatr Soc. 2010;58(2):364-70.)
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USA, Johns Hopkins Cohort study |
Geriatric nurse and a geriatric doctor |
Education of older adults and caregivers about medications and self-management skills before hospital discharge. Guidance provided 48 hours after discharge, via fax, describing the hospitalization and changes in the medication regimen. Use of phone calls to patients or caregivers reviewing symptoms, medication use, self-management skills. |
Buurman et al., 2016(1616. Buurman BM, Parlevliet JL, Allore HG, Blok W, van Deelen BA, Moll van Charante EP, et al. Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients: The Transitional Care Bridge Randomized Clinical Trial. JAMA Intern Med. 2016;176(3):302-9.)
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Netherlands Double-blind, multicenter, randomized clinical trial |
Community care nurse |
Comprehensive geriatric assessment Discussion about care plans, needs and treatments before discharge, involving nurses, older adults and informal caregivers Assessment of older adults’ needs, medication reconciliation and clarification of doubts after hospital discharge. |
Chareh et al., 202(1717. Chareh N, Rappl A, Rimmele M, Wingenfeld K, Freiberger E, Sieber CC, et al. Does a 12-Month Transitional Care Model Intervention by Geriatric-Experienced Care Professionals Improve Nutritional Status of Older Patients after Hospital Discharge? A Randomized Controlled Trial. Nutrients. 2021;13(9):3023.)
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Germany Secondary analysis of Non-Blinded Randomized Controlled Trial |
Nurses (n=5), a case manager and an occupational therapist |
Development of comprehensive individualized care plans involving healthcare professionals, older adults and family members. Assessment of nutritional problems, functionality, cognition, medication management, home environment conditions, difficulties in Basic Activities of Daily Living and self-care of older adults at home |
Stauffer et al., 2011(1818. Stauffer BD, Fullerton C, Fleming N, Ogola G, Herrin J, Stafford PM, et al. Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. Arch Intern Med. 2011;171(14):1238-43.)
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USA, Dallas-Fort Worth, northern Texas Pilot study |
Advanced practice nurses |
Education of older adults and caregivers 72 hours after discharge to establish goals, guide them about the severity of heart failure, review behavior and general health skills. |
Jepma et al., 2021(1919. Jepma P, Latour CH, Ten Barge IH, Verweij L, Peters RJ, Scholte Op Reimer WJM, et al. Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study. BMC Health Serv Res. 2021;21(1):786.)
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Netherlands Multicenter Randomized Controlled Trial |
Nurse-led program |
Comprehensive geriatric assessment to identify geriatric conditions and develop an integrated care plan. Delivery of the integrated care plan to older adults to prepare for discharge. Home visits for medication reconciliation, early warning of worsening, health complications and assessment of the care plan. |
Finlayson et al., 2018(2020. Finlayson K, Chang AM, Courtney MD, Edwards HE, Parker AW, Hamilton K, et al. Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults. BMC Health Serv Res. 2018;18(1):956.)
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Australia Randomized Controlled Trial |
Nurses and an exercise physiologist |
Home visit 48 hours after discharge to assess: 1. Sufficient caregiver support for older adults 2. Safety of the home environment, 3. Access to medicines and dressings, 4. Understanding the medication regimen and treatment 5. Reinforcement of the exercise program and use of pedometer at home 6. Caregiver advice and support |