Table 1
Study characteristics of included studies.
| STUDY | COUNTRY | STUDY DESIGN | TCM NAME | SAMPLE SIZE | MEAN AGE (YEARS) | INCLUSION CRITERIA |
|---|---|---|---|---|---|---|
| Brand (2004) | Australia | Quasi-experimental | / | IG: 83 CG: 83 | IG: 77.5 CG: 79.6 | ≥65 years Inpatient stay >24 hours At least one risk criteria: admission in past six months, two or more actively treated comorbidities, admitted because of chronic heart failure |
| Buurman (2016) | Netherlands | RCT | Transitional Care Bridge Intervention | IG:316 CG:303 | IG:79.7 CG:80.0 | ≥65 years At least 48 hours admitted to internal medicine At risk for functional decline risk score based on the Identification of Seniors at Risk Hospitalized Patients score |
| Coleman (2004) | US | Quasi-experimental | The Care Transitions Intervention | IG:158 CG:1235 | IG:75.1 CG:78.4 | ≥65 years Community-dwelling At least one of nine diagnoses: congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, diabetes mellitus, stroke, medical and surgical back conditions (predominantly spinal stenosis), hip fracture, peripheral vascular disease, and cardiac arrythmias |
| Coleman (2006) | US | RCT | The Care Transitions Intervention | IG:376 CG:371 | IG:76.0 CG:76.4 | ≥65 years Community-dwelling Admitted for nonpsychiatric condition No documentation of dementia No plans to enter hospice At least one of 11 diagnoses: stroke, congestive heart failure, coronary artery disease, cardiac arrhythmias, chronic obstructive pulmonary disease, diabetes mellitus, spinal stenosis, hip fracture, peripheral vascular disease, deep venous thrombosis, and pulmonary embolism |
| Courtney (2009) | Australia | RCT | Older Hospitalised Patients’ Discharge Planning and In-home Follow-up Protocol (OHP-DP) | IG:49 CG:58 | IG:78.1 CG:79.4 | ≥65 years Admitted with a medical diagnosis At least one risk factor for readmission: ≥75 years, multiple admissions in previous 6 months, multimorbidity, living alone, lack of social support, moderate to severe functional impairment, history of depression |
| Gregersen (2012) | Denmark | Retrospective design with two historical cohorts | / | IG:233 CG:262 | IG:82.6 CG:82.1 | ≥65 years Admitted to the orthopaedic department Primary diagnosis of hip fracture |
| Huckfeldt (2019) | US | Quasi-experimental | Safe Transitions for At Risk Patients (STAR) | IG:202 CG1: 4142, CG2: 4592 | / | ≥75 years With one or more defined conditions: hospital admission in past 30 days, altered mental status or dementia, fall or syncope, volume depletion, dehydration, acute kidney injury, shortness of breath, generalized weakness, failure to thrive |
| Lembeck (2019) | Denmark | RCT | / | IG:270 CG:267 | IG:82.5 CG:82.2 | ≥65 years Minimum three out of nine defined medical and social conditions: cognitive and psychiatric disorders, drug and alcohol abuse, lack of social network, low level of functioning, multiple medications, hospital contacts in previous six months, falls history, housing conditions that hamper the patient in his daily activities. |
| Lim (2013) | Australia | RCT | Post- Acute Care (PAC) Intervention | IG:311 CG:287 | IG:76.5 CG:76.8 | Admitted to acute ward for over 48 hours, Discharged home Expected to live at least one month post discharge Requiring community services at discharge Mobility or self-care management problem OR fulfilling two or more defined factors: living alone, taking care of other at home, using community services before admission |
| Naylor (2004) | US | RCT | Discharge planning and home follow-up protocol | IG:118 CG:121 | IG:76.4 CG:75.6 | ≥65 years Community-dwelling Heart failure diagnosis Being alert and oriented |
| Ornstein (2011) | US | Pre-post design | / | IG:532 CG:628 | IG:81.1 CG:/ | Not reported |
| Parry (2009) | US | RCT | The Care Transitions Intervention | IG:44 CG:42 | IG:80.5 CG:82.8 | ≥65 years Community-dwelling Admitted for nonpsychiatric condition No documentation of dementia No plans to enter hospice At least one of 11 diagnoses: stroke, congestive heart failure, coronary artery disease, cardiac arrhythmias, chronic obstructive pulmonary disease, diabetes mellitus, spinal stenosis, hip fracture, peripheral vascular disease, deep venous thrombosis, and pulmonary embolism |
| Rebello (2017) | US | Retrospective analysis of a clinical demonstration | The PILL program | IG:100 CG:100 | IG:74.5 CG:74.4 | ≥65 years Acute admission and discharged home Lived in rural or highly rural area Patients fulfilling one or more defined risk factors were prioritized: ≥75 years, polypharmacy, cognitive impairment, congestive heart failure |
| Shakib (2016) | Australia | Retrospective case-control study | Multidisciplinary Ambulatory Consulting Service (MACS) | IG:252 CG:1008 | IG:77.0 CG:77.0 (median years) | ≥65 years Two or more chronic conditions At least two MACS clinic visits |
| Simpson (2019) | US | Matched case-control study | Bundled Help (Hospital Elder Life Program) | IG:148 CG:148 | / | ≥65 years At least one risk factor for ADL impairment, vision and/or hearing impairment, or dehydration |
| Villars (2013) | France | Quasi-experimental before and after design | / | IG1: 222, IG2: 168 CG:/ | IG:81.8 CG:/ | Hospitalized in the Special Alzheimer Acute Care Unit At least one of the emergency room re-hospitalization risks: severe disruptive BPSD, change of living arrangement related to BPSD, exhaustion of the principal caregiver, discharge with anosognosia while living alone in the community |
| Wee (2014) | Singapore | Retrospective cohort study | Aged Care Transition | IG:4132 CG:4132 | IG:79.2 CG:79.1 | At least one of the following criteria: ≥65 years, multimorbidity, ≥ five medications, impaired mobility or functional decline, impaired self-care skills, poor cognitive status, catastrophic injury, chronic illness, living alone or poor social support, multiple hospitalizations or ED visits in last six months |
[i] US = United States, RCT = Randomised controlled trial.
Table 2
TCMs mapped to the micro level of the SELFIE framework.
| SERVICE DELIVERY | LEADERSHIP & GOVERNANCE | WORKFORCE | FINANCING | TECHNOLOGIES & MEDICAL PRODUCTS | INFORMATION & RESEARCH | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| PERSON-CENTRED | TAILORED | SELF-MANAGEMENT | PRO-ACTIVE | INFORMAL CAREGIVER INVOLVEMENT | TREATMENT INTERACTION | CONTINUITY | SHARED DECISION-MAKING | INDIVIDUALIZED CARE PLANNING | COORDINATION TAILORED TO COMPLEXITY | MULTI-DISCIPLINARY TEAM | NAMED COORDINATOR | CORE GROUP | COVERAGE & REIMBURSEMENT | OUT OF POCKET COSTS | FINANCIAL INCENTIVES | EMRS & PATIENT PORTALS | E-HEALTH TOOLS | ASSISTIVE TECHNOLOGIES | REMOTE MONITORING | INDIVIDUAL LEVEL DATA | INDIVIDUAL RISK PREDICTION | |
| Studies with a significant impact on hospital readmissions and/or ED visits | ||||||||||||||||||||||
| Coleman (2004 & 2006), Parry (2009) | x | x | x | x | x | x | x | x | x | x | GNP | / | x | x | x | |||||||
| Courtney (2009) | x | x | x | x | x | x | x | x | x | x | RN | RN, physio-therapist | x | x | x | |||||||
| Naylor (2004) | x | x | x | x | x | x | x | x | x | x | x | APN | APN, physicians | x | x | x | ||||||
| Rebello (2017) | x | x | x | x | x | x | x | x | x | PILL pharmacist | PILL pharmacist, Pill program manager | x | x | x | ||||||||
| Wee (2014) | x | x | x | x | x | x | x | x | x | x | RN or MSW | RN/MSW, project director, clinician leader | x | x | ||||||||
| Studies with a non-significant impact on hospital readmissions and/or ED visits | ||||||||||||||||||||||
| Brand (2004) | x | x | x | x | x | x | x | x | x | CDNC | CDNC, GP | x | x | |||||||||
| Buurman (2016) | x | x | x | x | x | x | x | x | x | x | x | CCRN | CCRN, RN, geriatrician | x | x | |||||||
| Gregersen (2012) | x | x | x | x | x | x | x | x | x | / | geriatrician, physio- therapist, nurse | x | x | x | ||||||||
| Huckfeldt (2019) | x | x | x | x | x | x | x | x | x | x | HHN | HHN, geriatrician, nurse | x | x | ||||||||
| Lembeck (2019) | x | x | x | x | x | x | x | PN | PN, MN, DN | x | x | x | ||||||||||
| Lim (2013) | x | x | x | x | x | x | Allied health staff or nurse | / | x | x | x | |||||||||||
| Ornstein (2011) | x | x | x | x | x | x | x | x | x | x | NP | NP, PCP, inpatient care team | x | x | x | x | x | |||||
| Shakib (2016) | x | x | x | x | x | x | x | x | x | x | / | / | x | x | x | x | ||||||
| Simpson (2019) | x | x | x | x | x | x | x | x | Geriatrician or NS or ELS | ELNS, RN, CNA, PT, OT, ST | x | x | ||||||||||
| Villars (2013) | x | x | x | x | x | x | x | x | x | x | / | / | x | x | ||||||||
[i] CDNC = chronic disease nurse consultant, CCRN = community care registered nurse, RN = registered nurse, APN = advanced practice nurse, NP = nurse practitioner, NS = nurse specialist, GNP = geriatric nurse practitioner, HHN = Home health nurse, MN = municipal nurse, PN = project nurse, DN = Discharging nurse, ELNS = elder life nursing specialist, ELS = elder life specialist, CNA = certified nursing assistant, PT = physical therapist, OT = occupational therapist, ST = speech therapist, MSW = medical social worker, EMR = electronic medical record.
Table 3
Outcome measures categorized by service, patient, provider and process outcomes and ranked based on frequency of reporting.
| CATEGORY | OUTCOME VARIABLE | # OF STUDIES REPORTED | % OF REPORTED STUDIES | FIRST REPORTED STUDY YEAR | LAST REPORTED STUDY YEAR | CONTINENT | ||
|---|---|---|---|---|---|---|---|---|
| US | EU | APAC | ||||||
| Service outcomes | Hospital readmission | 17 | 100% | 2004 | 2019 | 8 | 4 | 5 |
| ED visits | 9 | 53% | 2004 | 2019 | 4 | 1 | 4 | |
| Average length of hospital stay | 6 | 35% | 2004 | 2019 | 3 | 1 | 2 | |
| Total intervention cost | 6 | 35% | 2004 | 2017 | 5 | 0 | 1 | |
| Health care cost | 4 | 24% | 2004 | 2013 | 3 | 0 | 1 | |
| GP visits | 3 | 18% | 2004 | 2019 | 0 | 1 | 2 | |
| Other community service use | 3 | 18% | 2013 | 2019 | 1 | 1 | 1 | |
| Discharge destination | 3 | 18% | 2004 | 2016 | 1 | 1 | 1 | |
| Total number of hospital days | 2 | 12% | 2004 | 2019 | 1 | 1 | 0 | |
| Time to first unplanned re-hospitalization | 2 | 12% | 2004 | 2016 | 2 | 0 | 0 | |
| Rehospitalization for same diagnosis as index hospitalization | 2 | 12% | 2006 | 2009 | 2 | 0 | 0 | |
| Proportion of preventable readmissions | 1 | 6% | N/A | 2019 | 0 | 1 | 0 | |
| Minutes per day among patients receiving municipal services | 1 | 6% | N/A | 2019 | 0 | 1 | 0 | |
| Change in minutes per day before to after discharge | 1 | 6% | N/A | 2019 | 0 | 1 | 0 | |
| New fracture | 1 | 6% | N/A | 2009 | 0 | 1 | 0 | |
| Time to first ED visit | 1 | 6% | N/A | 2004 | 1 | 0 | 0 | |
| Complicated posthospital episode | 1 | 6% | N/A | 2004 | 1 | 0 | 0 | |
| Average Number of readmissions following discharge from index admission | 1 | 6% | N/A | 2016 | 1 | 0 | 0 | |
| Case-mix index | 1 | 6% | N/A | 2011 | 1 | 0 | 0 | |
| Patient outcomes | Mortality | 10 | 59% | 2004 | 2019 | 3 | 4 | 3 |
| Health related Quality of life | 5 | 29% | 2004 | 2013 | 1 | 1 | 3 | |
| Activities of daily living | 2 | 12% | 2013 | 2016 | 0 | 2 | 0 | |
| Functional status | 2 | 12% | 2004 | 2016 | 1 | 1 | 0 | |
| Patient satisfaction | 2 | 12% | 2004 | 2014 | 1 | 0 | 1 | |
| Personalized health goal | 1 | 6% | N/A | 2009 | 1 | 0 | 0 | |
| Provider outcomes | Caregiver burden | 1 | 6% | N/A | 2013 | 0 | 0 | 1 |
| Provider feedback | 1 | 6% | N/A | 2011 | 1 | 0 | 0 | |
| Process outcomes | Reported process outcome | 13 | 76% | 2004 | 2019 | 7 | 3 | 3 |
[i] APAC = Asia-Pacific (including Australia), EU = Europe, US = United States, N/A = not applicable, GP = general practitioner, ED = emergency department.
Table 4
Impact of TCMs on hospital readmission and ED visit outcomes.
| HOSPITAL READMISSION (%) | ED VISITS (%) | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| LESS THAN 1 MONTH | 1 MONTH | 2–3 MONTHS | 5–6 MONTHS | 1 YEAR | LESS THAN 1 MONTH | 1 MONTH | 2–3 MONTHS | 5–6 MONTHS | |
| Brand (2004) | IG: 36.1 CG: 36.1 | IG: 31.3 CG: 25.3 | IG: 8.4 CG: 8.4 | IG: 21.7 CG: 18.1 | |||||
| Buurman (2016) | IG: 33.5 CG:29.0 | ||||||||
| Coleman (2004) | IG: 8.9 CG: 13.8 | IG: 13.5 ** CG: 22.0 | IG: 22.9 * CG: 32.0 | IG: 11.0 CG: 14.2 | IG: 18.3* CG: 25.7 | IG: 37.1 CG: 36.0 | |||
| Coleman (2006) | IG: 8.3* CG: 11.9 | IG: 16.7* CG: 22.5 | IG: 25.6 CG: 31.0 | ||||||
| Courtney (2009) | IG: 22.0** CG: 46.7 | IG: 28.5 CG: 46.5 | |||||||
| Gregersen (2012) | IG: 13 CG: 12 | IG: 27 CG: 26 | |||||||
| Huckfeldt (2019) | IG: 5.9 CG1: 4.9 CG2: 5.9 | IG: 18.3 CG1: 14.3 CG2: 14.6 | IG: 5.0 CG1: 2.9 CG2: 3.2 | IG: 10.9 CG1: 7.2 CG2: 7.9* | |||||
| Lembeck (2019) | IG: 11 CG: 10 | IG: 30 CG: 26 | IG: 56 CG: 54 | ||||||
| Lim (2013) | IG: 25 CG: 28 | IG: 6 CG: 6 | |||||||
| Naylor (2004) | IG: 104 (n)* CG: 162 (n) | ||||||||
| Ornstein (2011) | IG: 15.7 CG: 16.6 | ||||||||
| Parry (2009) | IG: 6.8 CG: 16.7 | IG: 9.3** CG: 31.0 | IG: 20.9 CG: 38.1 | ||||||
| Rebello (2017) | IG: 10 CG: 10 | IG: 13 CG: 15 | IG: 7 CG: 20 OR = 0.30 (.12–.75) | IG: 16 CG: 26 | |||||
| Shakib (2016) | IG: 21 CG: 23.9 | ||||||||
| Simpson (2019) | IG: 16.8 CG: 28.4 | IG: 10.8 CG: 15.5 | IG: 10.8 CG: 15.5 | ||||||
| Villars (2013) | IG1: 13.31 IG2: 13.19 CG: 16.07 | IG1: 24.03 IG2: 23.58 CG: 28.98 | |||||||
| Wee (2014) | IG: 10.0*** CG: 21.3 | IG: 15.6*** CG: 27.7 | IG: 15.6*** CG: 27.7 | IG: 37.9** CG: 51.6 | IG: 19.3*** CG: 32.0 | IG: 46.3* CG: 57.9 | |||
[i] ***= p ≤ .001, **= p ≤ .01, *= p ≤ .05, OR = Odds Ratio, (n) = number.
Figure 1
Overview of the screening and selection process using the PRISMA flow chart.