Impact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence Review

Abstract

Transitions in care from hospital to primary care for older patients with chronic diseases (CD) are complex and lead to increased mortality and service use. In response to these challenges, transitional care (TC) interventions are being widely implemented. They encompass education on self-management, discharge planning, structured follow-up and coordination among the different healthcare professionals. We conducted a systematic review to determine the effectiveness of interventions targeting transitions from hospital to the primary care setting for chronically ill older patients.. Randomized controlled trials were identified through Medline, CINHAL, PsycInfo, EMBASE (1995-2015). Two independent reviewers performed the study selection, data extraction and assessment of study quality (Cochrane "Risk of Bias"). Risk differences (RD) and number needed to treat (NNT) or mean differences (MD) were calculated using a random-effects model. From 10,234 references, 92 studies were included. Compared to usual care, significantly better outcomes were observed: a lower mortality at 3 (RD: -0.02 [-0.05, 0.00]; NNT: 50), 6, 12 and 18 months post-discharge, a lower rate of ED visits at 3 months (RD: -0.08 [-0.15, -0.01]; NNT: 13), a lower rate of readmissions at 3 (RD: -0.08 [-0.14, -0.03]; NNT: 7), 6, 12 and 18 months and a lower mean of readmission days at 3 (MD: -1.33; [-2.15, -0.52]), 6, 12 and 18 months. No significant differences were observed in quality of life. In conclusion, TC improves transitions for older patients and should be included in the reorganization of healthcare services.

How older people enact care involvement during transition from hospital to home: A systematic review and model

“…In the wider literature, communication skills training is a recognized component of self‐management . Evidence of training, however, is not apparent in existing transition interventions for older people, and in the studies in the current review, use of such skills was not apparent. Reasons are likely to vary, but the hospital setting itself is likely to be a factor.…”

“…Interventions aiming to support older people to transition from hospital to home have been the subject of numerous systematic reviews . Self‐management and/or education, as a way of empowering individuals to be involved in and take control of their care, was the second most common component of these multicomponent interventions .…”

University of Pittsburgh Medical Center Home Transitions Multidisciplinary Care Coordination Reduces Readmissions for Older Adults

“…Enhanced emergency planning and greater “on call” presence of homecare staff could help reduce observation and ED visits . The results of this study are consistent with previous literature evaluating CTPs . An important contribution of this study is quantification of the role of NP and SW home visits, which had been a gap .…”

“…CTPs are described extensively in the literature, with models ranging from unimodal, disease‐specific interventions to multimodal comprehensive care coordination models. Reviews of CTPs suggest that multimodal, multidisciplinary interventions spanning time and settings are most effective for achieving positive outcomes . A seminal randomized controlled trial of the Care Transitions Intervention demonstrated that a multimodal model can reduce hospital readmissions of individuals with complex care needs .…”

“…Using core elements from these programs and others, CTPs have been implemented and studied in various settings and populations . Further evidence from multidisciplinary, multimodal models implemented in nonresearch settings is necessary to determine the most effective models …”