Nursing team strategies for caring for older adults in the hospital-home transition: an integrative review

Associate Editor: Meiry Fernanda Pinto Okuno (https://orcid.org/0000-0003-4200-1186) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brasil

Conflicts of interest: nothing to declare.

Authors/year	Titles	Database	Journal	Impact factor
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.⁾	Eliciting nurses’ perspectives to improve health information exchange between hospital and home health care	CINAHL	Geriatr. Nurs.	2.525
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.⁾	Development of a senior-specific, citizen-oriented healthcare service system in South Korea based on the Canadian 48/6 model of care	CINAHL	BMC Geriatrics	4.070
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.⁾	Evaluation of a care transition program with pharmacist-provided home-based medication review for elderly Singaporeans at high risk of readmissions	CINAHL	Int. J. Qual. Health Care	2.257
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.⁾	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	Web of Science	Arch. Gerontol. Geriatr.	4.163
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.⁾	The Effectiveness of a Timely Discharge Plan in Older Adults: A Prospective Hospital-Based Cohort Study in Southern Taiwan	Web of Science	Aging Med. Healthcare	0.26
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.⁾	Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners’ Perspectives	PubMed	Int. J. Integr. Care	2,913
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.⁾	The continuity of hospital nursing care for Primary Health Care in Spain	Scopus	Rev. Esc. Enferm. USP	1.123
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.⁾	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	VHL Regional Portal	BMC Health Serv. Res.	2.908
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.⁾	The Geriatric Floating Interdisciplinary Transition Team	VHL Regional Portal	J. Am. Geriatr. Soc.	7.538
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.⁾	Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients: The Transitional Care Bridge Randomized Clinical Trial	VHL Regional Portal	JAMA Intern. Med.	44.424
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.⁾	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	CINAHL	Nutrients	6.706
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.⁾	Effectiveness and Cost of a Transitional Care Program for Heart Failure A Prospective Study With Concurrent Controls	CINAHL	JAMA Intern. Med.	44.424
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.⁾	Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study	CINAHL	BMC Health Serv. Res.	2.908
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.⁾	Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults	CINAHL	BMC Health Serv. Res	2.908

Authors/year	Country Study design	Participants	Nursing team strategies for hospital-home transition care
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.⁾	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.⁾	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.⁾	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.⁾	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.⁾	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.⁾	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.⁾	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.⁾	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.⁾	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.⁾	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.⁾	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.⁾	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.⁾	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.⁾	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

Categories

Studies that addressed the content

Care strategies performed by nursing in the hospital environment for the transition from home care

⁽ 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.

9. 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. ^- 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. ^- 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. ^- 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. ^- 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. ^- 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. ^- 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. ^- 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. ^- 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. ^- 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. ^- 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. ⁾

Strategies performed by nursing for continuity of care in the community

⁽ 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. ^- 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. ^- 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. ^- 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.

11. 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. ^- 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. ^- 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. ^- 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. ^- 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. ^- 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. ^- 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. ^- 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. ^- 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. ^- 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. ⁾

[1] Corresponding author: Jessica Lane Pereira Santos E-mail: jessicalane84@gmail.com

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Nursing team strategies for caring for older adults in the hospital-home transition: an integrative review

Abstract

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Methods

Results

Conclusion