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. 2024 Feb;33(2):481-496.
doi: 10.1111/jocn.16913. Epub 2023 Dec 18.

Transitional care model for older adults with multiple chronic conditions: An evaluation of benefits utilising an umbrella review

Connie Berthelsen  1   2 , Nicoline Møller  3 , Gitte Bunkenborg  2   4
Affiliations

Transitional care model for older adults with multiple chronic conditions: An evaluation of benefits utilising an umbrella review

Connie Berthelsen et al. J Clin Nurs. 2024 Feb.

Abstract

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.

Keywords: multiple chronic conditions; older patients; patient satisfaction; quality of life; readmission; reduced costs; transitional care model; umbrella review.

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References

REFERENCES

    1. Albert, N. M. (2016). A systematic review of transitional-care strategies to reduce rehospitalization in patients with heart failure. Heart & Lung, 45, 100-113. https://doi.org/10.1016/j.hrtlng.2015.12.001
    1. Allen, J., Hutchinson, A. M., Brown, R., & Livingston, P. (2014). Quality care outcomes following transitional care interventions for older people from hospital to home: A systematic review. BMC Health Services Research, 14, 346 http://www.biomedcentral.com/1472-6963/14/346
    1. Altfeld, S. J., Shier, G. E., Rooney, M., Johnson, T. J., Golden, R. L., Karavolos, K. J., Avery, E., Nandi, V., & Perry, A. J. (2013). Effects of an enhanced discharge planning intervention for hospitalized older adults: A randomized trial. The Gerontologist, 53(3), 430-440. https://doi.org/10.1093/geront/gns109
    1. Amjad, H., Wong, S. K., Roth, D. L., Huang, J., Willink, A., Black, B. S., Johnston, D., Rabins, P. V., Gitlin, L. N., Lyketsos, C. G., & Samus, Q. M. (2018). Health services utilization in older adults with dementia receiving care coordination: The MIND at home trial. Health Services Research, 53(1), 556-579. https://doi.org/10.1111/1475-6773.12647
    1. Aromatis, E., Fernandez, R., Godfrey, C. M., Holly, C., Khalil, H., & Tungpunkom, P. (2015). Summarizing systematic reviews: Methodological development, conduct and reporting of an umbrella review approach. International Journal of Evidence-Based Healthcare, 13, 132-140. https://doi.org/10.1097/XEB.0000000000000055

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