Key result
Transitional Care Model elements reduce readmissions and costs while improving quality of life and satisfaction.
Why the study?
Older patients with multiple chronic conditions are increasing worldwide with complicated trajectories, and the Transitional Care Model may support transitions between hospital and home.
Do interventions using elements from the Transitional Care Model improve outcomes for older patients with multiple chronic conditions transitioning from hospital to home?
Systematic Review
Do interventions using elements from the Transitional Care Model improve outcomes for older patients with multiple chronic conditions transitioning from hospital to home?
The Transitional Care Model, particularly elements focusing on coordination, continuity, and patient education, significantly improves outcomes such as readmissions and quality of life for older adults with multimorbidity.
Answers are grounded in this paper and cite their sources.
Supports Transitional Care Model elements in discharge planning for older multimorbid adults; reinforces reductions in readmissions and costs with better quality of life.
AIMS: To synthesise and describe the combined evidence from systematic reviews of interventions using elements from the Transitional Care Model, on the content and timeframe of the interventions and the related improvement of outcomes for older patients with multiple chronic conditions. BACKGROUND: The population of older patients with multiple chronic conditions is increasing worldwide and trajectories are often complicated by risk factors. The Transitional Care Model may contain elements to support transitions between hospital and home. DESIGN: An umbrella review. REVIEW METHODS: A comprehensive search in five electronic databases was performed in April 2021 based on the search terms: 'Patients ≥60 years,' 'multi-morbidity,' 'Transitional care model,' 'Transitional care,' and 'Systematic review.' PRISMA guidelines was used. RESULTS: Five systematic reviews published from 2011 to 2020 comprising 62 intervention studies (59 randomised controlled trials and three quasi-experimental trials) were included in the review. The synthesis predominantly revealed significant improvements in decreasing re-admissions and financial costs and increasing patients' quality of life and satisfaction during discharge. CONCLUSION: The results of the review indicate that multiple elements from the Transitional Care Model have achieved significant improvements in older patients' transitions from hospital to home. Especially a combination of coordination, communication, collaboration and continuity of care in transitions, organised information and education for patients and pre-arranged structured post-discharge follow-ups. IMPACT: The transition from hospital to home is a complex process for older patients with multiple chronic conditions. A specific focus on coordination, continuity, and patient education should be implemented in the discharge process. Nurses with specialised knowledge in transitional care are needed to ensure safe transitions. PATIENT AND PUBLIC CONTRIBUTION: The umbrella review is part of a larger research program which involved a patient expert advisory board, which participated in discussing the relevance of the elements within the umbrella review.
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Berthelsen et al. (2023) conducted a systematic review in Multiple chronic conditions. Transitional Care Model was evaluated on Re-admissions, financial costs, quality of life, and satisfaction during discharge. Interventions using elements from the Transitional Care Model significantly decreased re-admissions and financial costs, and increased quality of life and satisfaction during discharge.
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