Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Jun 29;22(2):28.
doi: 10.5334/ijic.6447. eCollection 2022 Apr-Jun.

Integrated Care Components in Transitional Care Models from Hospital to Home for Frail Older Adults: A Systematic Review

Merel Leithaus  1   2 , Audrey Beaulen  2   3 , Erica de Vries  2   3 , Geert Goderis  4 , Johan Flamaing  5   6 , Hilde Verbeek  2   3 , Mieke Deschodt  5   7
Affiliations

Integrated Care Components in Transitional Care Models from Hospital to Home for Frail Older Adults: A Systematic Review

Merel Leithaus et al. Int J Integr Care. .

Abstract

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.

Keywords: frail older adult; integrated care; systematic review; transitional care.

PubMed Disclaimer

Conflict of interest statement

The authors have no competing interests to declare.

Figures

Overview of the screening and selection process using the PRISMA flow chart
Figure 1
Overview of the screening and selection process using the PRISMA flow chart.
See this image and copyright information in PMC

References

    1. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. The Lancet. 2013; 381(9868): 752–62. Available from: https://pubmed.ncbi.nlm.nih.gov/23395245/. DOI: 10.1016/S0140-6736(12)62167-9 - DOI - PMC - PubMed
    1. Nwadiugwu MC. Frailty and the Risk of Polypharmacy in the Older Person: Enabling and Preventative Approaches. Journal of aging research. 2020; 2020: 6759521. DOI: 10.1155/2020/6759521 - DOI - PMC - PubMed
    1. Courtney M, Edwards H, Chang A, Parker A, Finlayson K, Hamilton K. Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program. Journal of the American Geriatrics Society. 2009; 57(3): 395–402. Available from: https://pubmed.ncbi.nlm.nih.gov/19245413/. DOI: 10.1111/j.1532-5415.2009.02138.x - DOI - PubMed
    1. Laugaland K, Aase K, Barach P. Addressing Risk Factors for Transitional Care of the Elderly – Literature review. 2011.
    1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine. 2003; 138(3): 161–7. Available from: https://pubmed.ncbi.nlm.nih.gov/12558354/. DOI: 10.7326/0003-4819-138-3-200302040-00007 - DOI - PubMed

LinkOut - more resources