Integrated Care Approaches Used for Transitions from Hospital to Community Care: A Scoping Review

Abstract

Integrated care is a promising approach for improving care transitions for older adults, but this concept is inconsistently defined and applied. This scoping review describes the size and nature of literature on integrated care initiatives for transitions from hospital to community care for older adults (aged 65 and older) and how this literature conceptualizes integrated care. A systematic search of literature from the past 10 years yielded 899 documents that were screened for inclusion by two reviewers. Of the 48 included documents, there were 26 journal articles and 22 grey literature documents. Analysis included descriptive statistics and a content analysis approach to summarize features of the integrated care initiatives. Results suggest that clinical and service delivery integration is being targeted rather than integration of funding, administration, and/or organization. To promote international comparison of integrated care initiatives aiming to improve care transitions, detailed descriptions of organizational context are also needed.

Health, Social, and Functional Characteristics of Older Adults With Continuing Care Needs: Implications for Integrated Care

“…An ongoing relationship between an intensive case manager and the patient could have allowed for earlier intensive intervention implementation for patients with difficult to manage symptoms or behaviors, the development of trust with older adults and families reluctant to accept services, ongoing support for informal caregivers, and a liaison between settings for needed hospital admissions. At a clinical level, integrated care uses interprofessional teams that deliver rehabilitative and restorative care in the community to best manage problematic symptoms and behaviors and reduce the need for hospital convalescence (Brown & Menec, 2018; Threapleton et al, 2017).…”

“…The nature of the concerns and issues expressed by community care professionals and family elucidates the features of integrated care that would be beneficial to the older adults in this study. At a macro level, integrated care approaches emphasize the need for a psychosocial as well as medical approach to care (Brown & Menec, 2018;Chappell & Hollander, 2013;Threapleton et al, 2017). The patients in this study had psychosocial needs including mental and behavioral needs, social support needs, and need for support for informal caregivers, all of which are prioritized in an integrated care approach.…”

“…At a clinical level, integrated care approaches use case managers who provide care across settings for continuity (Brown & Menec, 2018;Chappell & Hollander, 2013;Threapleton et al, 2017). An ongoing relationship between an intensive case manager and the patient could have allowed for earlier intensive intervention implementation for patients with difficult to manage symptoms or behaviors, the development of trust with older adults and families reluctant to accept services, ongoing support for informal caregivers, and a liaison between settings for needed hospital admissions.…”

“…An ongoing relationship between an intensive case manager and the patient could have allowed for earlier intensive intervention implementation for patients with difficult to manage symptoms or behaviors, the development of trust with older adults and families reluctant to accept services, ongoing support for informal caregivers, and a liaison between settings for needed hospital admissions. At a clinical level, integrated care uses interprofessional teams that deliver rehabilitative and restorative care in the community to best manage problematic symptoms and behaviors and reduce the need for hospital convalescence (Brown & Menec, 2018;Threapleton et al, 2017). Independent predictors of potentially avoidable hospital outcomes that were similar to other studies of hospitalized older adult populations were living alone (Sansosi et al, 2015), dementia and other mental conditions (Bressi Nath & Marcus, 2012;Fick et al, 2013;Harrison et al, 2017;Prina et al, 2013;Vivanco & Roberts, 2011;Zekry, 2012), cognitive impairment (Sansosi et al, 2015), and functional dependency (Harrison et al, 2017;Sansosi et al, 2015;Vivanco & Roberts, 2011).…”

Collaborative Experience Success Stories in Integrated Care of Older People: A Narrative Analysis

“…The call for integrated care has been induced by demographic change, increased fragmentation of the welfare sector and increased demand for technically and more expensive care solutions [ 1 2 ]. There is a wide variety of strategies and initiatives to improve care continuity and coordination for people with chronic diseases, not least for older people with complex care needs who require care from multiple providers [ 3 ]. Many factors have been emphasised as beneficial for the success of joint working and integration, for instance co-location, team building events and pooled budgets [ 2 4 ].…”