Interventions supporting older adults’ transition from hospital to home can address geriatric needs. Yet this evidence base is fragmented. This review describes transitional interventions that provide pre- and post-discharge support for older adults and evaluates their implementation and effectiveness in improving health and well-being.
Method:
Articles were included if they examined the extent to which transitional interventions were effective in improving health and well-being outcomes and reducing hospital readmission rates among older adults.
Results:
Twenty studies met the inclusion criteria. Four types of interventions were identified: education-based (10/20); goal-oriented (4/20); exercise (4/20); and social support interventions (2/20). Education and goal-oriented interventions were effective in improving health and well-being outcomes. The impact of interventions on mitigating hospital readmissions was inconclusive. Only five studies examined implementation.
Discussion:
Older adults transitioning from hospital to home would benefit from tailored education and goal-oriented interventions that promote their capacity for self-care.
AlbertS. (2019). The dynamics of frailty among older adults. Journal of the American Medical Association, 2(8), Article e198438.
2.
AllenJ.HutchinsonA.BrownR.LivingstonP. (2014). Quality care outcomes following transitional care interventions for older people from hospital to home: A systematic review. BMC Health Services Research, 14(1), Article 346.
3.
AndreasenJ.LundH.AadahlM.SorensenE. (2015). The experience of daily life of acutely admitted frail elderly patients one week after discharge from the hospital. International Journal of Qualitative Studies on Health and Wellbeing, 10(1), Article 27370.
4.
BraetA.WeltensC.SermeusW. (2016). Effectiveness of discharge interventions from hospital to home on hospital readmissions: A systematic review. JBI Database of Systematic Reviews and Implementation, 14, 106–173.
5.
*BurnsM.GalbraithA.Ross-DegnanD.BalabanR. (2014). Feasibility and evaluation of a pilot community health worker intervention to reduce hospital readmissions. International Journal for Quality in Health Care, 26(4), 358–365.
6.
CarvalhoK.SilvaC.FigueiredoM.NogueiraL.AndradeE. (2018). Educational interventions for health promotion of the elderly: Integrative review. Journal of Nursing, 31(4), 446–454.
7.
ChaseJ. (2013). Physical activity interventions among older adults: A literature review. Research and Theory for Nursing Practice, 27(1), 53–80.
8.
*ChowS.WongF. (2014). A randomised controlled trial of a nurse-led case management program for hospital-discharged older adults with co-morbidities. Journal of Advanced Nursing, 70(10), 2257–2271.
9.
*CourtneyM.EdwardsH.ChangA.ParkerA.FinlaysonK.HamiltonK. (2009). Fewer emergency readmissions and better quality of life for older adults at risk of hospital readission: A randomised controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program. Journal of the American Geriatrics Society, 57, 395–402.
10.
CoyleC.DuganE. (2012). Social isolation, loneliness, and health among older adults. Journal of Ageing and Health, 24(8), 1346–1363.
11.
FeltnerC.JonesC.CenéC.ZhengZ.SuetaC.Coker-SchwimmerE.. . .JonasD. (2014). Transitional care interventions to prevent readmissions for persons with heart failure: A systematic review and meta-analysis. Annals of Internal Medicine, 160(11), 774–784.
12.
*FinlaysonK.ChangA.CourtneyM.EdwardsH.ParkerA.HamiltonK.O’BrienJ. (2018). Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults. BMC Health Services Research, 18(956), 1–9.
13.
*GoldmanL.SarkarU.KessellE.GuzmanD.SchneidermannM.PierluissiE.. . .KushelM. (2014). Support from hospital to home for elders: A randomised trial. Annual Internal Medicine, 161(7), 472–481.
14.
HandleyM.LylesC.McCullochC.CattamanchiA. (2018). Selecting and improving quasi-experimental designs in effectiveness and implementation research. Annual Review of Public Health, 39, 5–25.
15.
HansenL.YoungR.HinamiK.LeungA.WilliamsM. V. (2011). Interventions to reduce 30-day rehospitalization: A systematic review. Annual Internal Medicine, 155(8), 520–528.
16.
*HarrisonM.BrowneG.RobertsJ.TugwellP.GafniA.GrahamI. (2002). Quality of life of individuals with heart failure: A randomised trial of the effectiveness of two models of hospital to home transition. Medical Care, 40(4), 271–282.
17.
*HuangT.LiangS. (2005). A randomised clinical trial of the effectiveness of a discharge planning intervention in hospitalised elders with hip fracture due to falling. Clinical Nursing, 14(10), 1193–1201.
18.
HirschmanK.HodgsonN. (2018). Evidence-based interventions for transitions in care for individuals living with dementia. Gerontologist, 58(1), 129–140.
19.
*Johnson-WarringtonV.ReesK.GelderC.MorganM.SinghS. (2016). Can a supported self-mangement program for COPD upon hospital discharge reduce admissions? A randomised controlled trial. International Journal of Chronic Obstructive Pulmonary Disease, 11, 1161–1169.
20.
*KwokT.LeeJ.WooJ.LeeD.GriffithS. (2008). A randomised conrolled trial of a community nurse-supported hospital discharge program in older patients with chronic heart failure. Journal of Clinical Nursing, 17(1), 109–117.
21.
LeighS. (2016). Poor communication premature discharges linked to patient readmissions, study shows. Revolving door of re-hospitalisations puts hospitals at risk of penalties. University of California San Francisco.
22.
*LinP.WangC.ChenC.LiaoL.KaoS.WuH. (2009). To evalute the effectiveness of a discharge-planning program for hip fracture patients. Journal of Clinical Nursing, 18(11), 1632–1639.
23.
*LindhardtT.LoevgreenS.BangB.BigumC.KlausenT. (2019). A targeted assessment and intervention at the time of discharge reduced the risk of readmissions for short-term hospitalised older patients: A randomised controlled study. Clinical Rehabilitation, 33(9), 1431–1444.
24.
*LindpaintnerL.GasserJ.ScharmmM.Cina-TschumiB.MullerB.BeerJ. (2013). Discharge intervention pilot improves satisfaction for patients and professionals. European Journal of Internal Medicine, 24(8), 756–762.
25.
LowthianJ.CurtisA.JolleyD.StoelwinderJ.McNeilJ.CameronP. (2012). Demand at the emergency department front door: 10-year trends in presentations. Medical Journal of Australia, 196, 128–132.
26.
MadeiraS.MeloM.PortoJ.MonteiroS.PereiradeMouraJ.AlexandrinoM.Alves MouraJ. (2007). The diseases we cause: Iatrogenic illness in a department of internal medicine. European Journal of Internal Medicine, 18(5), 391–399.
27.
MuradK.KitzmanD. (2012). Frailty and multiple comorbidities in the elderly patient with heart failure: Implications for management. Heart Failure Reviews, 17, 581–588.
28.
*NaylorM.BrootenD.CampbellR.MaislinG.McCauleyK.SchwartzJ. (2004). Transitional care of older adults hospitalised with heart failure: A randomised, controlled trial. Journal of the American Geriatrics Society, 52(5), 675–684.
29.
PowersB.MilsteinA.JainS. (2016). Delivery models for high-risk older patients: Back to the future?Journal of the American Medical Association, 315(1), 23–40.
30.
RayC.IngramV.Cohen-MansfieldJ. (2015). Systematic review of planned care transitions for persons with dementia. Neurodegenerative Disease Management, 5(4), 317–331.
31.
RhodesR.KatesA. (2015). Can the affective response to exercise predict future motives and physical activity behavior? A systematic review of published evidence. Annals of Behavioral Medicine, 49(5), 715–731.
32.
ScottT. (2010). Preventing the rebound: Improving care transition in hospital discharge processes. Australian Health Review, 34(4), 445–451.
33.
SharmaG.KuoY.FreemanJ.ZhangD.GoodwinJ. (2010). Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Archives of Internal Medicine, 170(18), 1664–1670.
34.
*ShyuY.LiangJ.TsengM.LiH.WuC.ChengH.YangC. (2016). Enhanced interdisciplinary care improves self-ability and decreases emergency department visits for older Taiwanese patients over two years after hip-fracture surgery: A randomised controlled trial. International Journal of Nursing Studies, 56, 54–62.
35.
*ThompsonD.RoebuckA.StewartS. (2005). Effects of a nurse-led, clinic and home-based intervention of recurrent hospital use in chronic heart failure. The European Journal of Heart Failure, 7(3), 377–384.
36.
United Nations. (2017). World population ageing. Department of Economic and Social Affairs, United Nations.
37.
*Van SpallH.LeeS.XieF.OzU.PerezR.MitoffP.ConnollyS. (2019). Effect of patient-centred transitional care services on clinical outcomes in patient hospitalised for heart failure. The PACT-HF randomised clinical trial. Journal of the American Medical Association, 321(18), 753–761.
38.
*WongF.ChowS.ChungL.ChangK.ChanT.LeeW.LeeR. (2008). Can home visits help reduce hospital readmissions? Randomised controlled trial. Journal of Advanced Nursing, 62(5), 585–595.
39.
*WongF.YeungS. (2015). Effects of a 4-week transitional care programme for discharged stroke survivors in Hong Kong: a randomised controlled trial. Health and Social Care in the Community, 23(6), 619-631.
40.
*ZhangP.XingF.LiC.WangF.ZhangX. (2017). Effects of a nurse-led transitional care program on readmission, self-efficacy to implement health-promoting behaviours, functioninal status and life quality among Chinese patients with coronary artery disease: A randomised controlled trial. Journal of Clinical Nursing, 27(5–6), 969–979.
41.
*ZhaoY.WongF. (2009). Effects of a postdischarge transitional care program for patients with coronary heart disease in China: A randomised controlled trial. Journal of Clinical Nursing, 18(17), 2444–2455.
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