Transitional care models featuring small care teams, intensive follow-up, shared decision making, and caregiver involvement were associated with reduced hospital readmissions and ED visits.
Systematic Review (n=17)
Do transitional care models with integrated care components reduce hospital readmissions and emergency department visits in frail older adults?
Transitional care models incorporating small care teams, intensive follow-up, shared decision making, and caregiver involvement may reduce hospital readmissions and ED visits in frail older adults.
Introduction: Frail older adults frequently experience transitions from hospital to home due to their complex care needs. Transitional care models (TCMs) are recommended to tackle adverse outcomes in frail patients. This review summarizes the use of integrated care components in addressing transitional care from hospital to home, provides an overview on reported outcomes and describes the impact of identified components on the outcomes hospital readmission and emergency department visit. Methods: This study is part of the European TRANS-SENIOR project. PubMed, CINAHL and Embase were searched for studies in English, German and Dutch that describe a TCM for frail older patients including both pre- and post-discharge components. Results: Seventeen studies, covering 15 TCMs were included. All TCMs describe a person-centred, tailored, pro-active and continuous transitional care service. Components like a small sized care team, intensive follow-up, shared decision making and informal caregiver involvement are likely to be associated with reduced hospital readmission and ED visits. Twenty-seven transitional care outcomes were reported: 19 service outcomes, six patient outcomes and two provider outcomes. Conclusion: Heterogeneity in content and outcomes complicates between-study comparison, yet several components were identified that improved care outcomes. Patient and provider outcomes should be included in future research.
Leithaus et al. (Wed,) conducted a systematic review in Frail older adults (n=17). Transitional care models (TCMs) was evaluated on Hospital readmission and emergency department visits. Transitional care models featuring small care teams, intensive follow-up, shared decision making, and caregiver involvement were associated with reduced hospital readmissions and ED visits.