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Review
. 2025 Jun 5;6(6):CD014713.
doi: 10.1002/14651858.CD014713.pub2.

Community care navigation intervention for people who are at risk of unplanned hospital presentations

Rebecca K Pang  1   2   3 , Brendan Shannon  4 , Taya Collyer  1   2 , Velandai Srikanth  1   2   5 , Nadine E Andrew  1   2
Affiliations
Review

Community care navigation intervention for people who are at risk of unplanned hospital presentations

Rebecca K Pang et al. Cochrane Database Syst Rev. .

Abstract

Background: Care navigation is a type of care co-ordination used to manage people with chronic conditions with the goal of reducing unplanned hospital presentations and improving patient care and outcomes. Care navigation involves individual case management by a trained professional who is not involved in the person's direct care. Care navigation has been used in various healthcare settings, adopted as a single or multi-component intervention by different health services. However, little is known about its effect on unplanned hospital presentations and patient-reported outcome measures (PROMs).

Objectives: Primary: to assess the effects of care navigation, delivered in the community, on hospital presentations and patient-reported outcome measures in people at risk of unplanned hospital presentations. Secondary: to assess whether the effects of community care navigation differ according to the type of clinician delivering the intervention and the populations receiving the intervention.

Search methods: We used CENTRAL, MEDLINE, four other databases and two clinical trial registers, together with reference checking, citation searching and contact with study authors to identify the studies included in this review. The latest search date was October 2024.

Selection criteria: We included randomised controlled trials (RCTs) and cluster-RCTs that recruited people who were at risk of hospital admission and utilised care navigation delivered in the community as an intervention. The comparison was usual care.

Data collection and analysis: Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We performed a meta-analysis of the results where possible, and a narrative synthesis of the remainder of the results. We present results in a summary of findings table, showing effect sizes for all outcomes.

Main results: We included 19 studies (36,745 participants), all conducted in high-income countries. Eighteen were RCTs. Of these, four studies were pragmatic non-blinded RCTs that randomised participants prior to obtaining consent. One study was a cluster-RCT. Follow-up ranged from one to 24 months. All studies included various healthcare professionals as care navigators: registered nurses in seven studies, social workers in five, and community health workers in one. In six studies, a multidisciplinary team delivered the care navigation intervention. The studies investigated the effects of community care navigation interventions in a variety of groups, including older people, those with chronic diseases (such as heart failure, chronic obstructive pulmonary disease, diabetes, mental health problems, cancer, alcohol and other drug use), people with complex psychosocial needs, high readmission risk and frequent emergency department users. All studies compared the intervention to usual care. Across the five risk of bias domains and where outcomes were reported, we deemed three of 42 study results to have 'some concerns' in at least one domain. Overall risk of bias across all domains ranged from 'low risk' in results reported in two studies to 'some concerns' or 'high risk' of bias across all other results. Overall, when inconsistency was also considered, we judged the certainty of the evidence to be very low or moderate. There may be little to no difference in unplanned hospital admission rates within one month (30 days) between community care navigation and usual care, but the evidence is very uncertain (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.79 to 1.14; P = 0.59; 5 studies, 3488 participants; very low-certainty evidence). However, community care navigation likely results in a reduction in unplanned hospital admission rates within 12 months (365 days) compared to usual care (RR 0.87, 95% CI 0.77 to 0.97; P = 0.01; 3 studies, 795 participants; moderate-certainty evidence). Community care navigation probably results in little to no difference in emergency department presentation rates within one month (30 days) compared to usual care (RR 1.09, 95% CI 0.92 to 1.29; P = 0.30; 3 studies, 4087 participants; moderate-certainty evidence) and in emergency department presentation rates within 12 months (365 days) (RR 0.99, 95% CI 0.91 to 1.08; P = 0.88; 2 studies, 873 participants; moderate-certainty evidence). None of the studies measured hospital presentations within three months (90 days). Eight studies reported different types of PROMs, collecting results at different time points. We narratively synthesised these results in the main text of the review, but could not determine the impact of community care navigation on PROMs due to the very low-certainty evidence. Community care navigation increases the proportion of patients having hospital outpatient appointments within one month (30 days) (RR 1.07, 95% CI 1.01 to 1.13; P = 0.02; 2 studies, 2178 participants; high-certainty evidence) compared to usual care, which may indicate that the intervention shifts patient care towards community services. We could not determine the impact of community care navigation on general practitioner (GP) visits, treatment satisfaction and quality of care due to the low- or very low-certainty evidence. No included study measured adverse events.

Authors' conclusions: Community care navigation for people at risk of unplanned hospital presentations is likely to reduce hospital admission rates within 12 months (365 days) and increase outpatient appointments within one month (30 days) compared to usual care, with moderate to high certainty of evidence. Results showed little to no effect on hospital admissions within one month (30 days) or on emergency department presentation rates compared to usual care. The evidence is very uncertain about the effect of community care navigation on health-related quality of life and quality of care. More robust studies are required to produce greater evidence certainty. Study risk of bias can be improved if future studies use traditional RCT designs and implement strategies to reduce dropout rates and reduce missing follow-up data.

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Conflict of interest statement

  1. Rebecca K Pang: no conflicts of interest to declare

  2. Brendan Shannon: no conflicts of interest to declare

  3. Taya Collyer: no conflicts of interest to declare

  4. Velandai Srikanth: no conflicts of interest to declare

  5. Nadine E Andrew: Australian Research Data Commons (Grant / Contract); Ian Potter Foundation (Grant / Contract); Faculty of Medicine, Nursing and Health Sciences, Monash University (Employment); Alfred Research Trusts, Alfred Health (Grant / Contract); Australian Epidemiology Association (Travel); Medical Research Future Fund (Grant / Contract); Australian Government, Department of Health (Grant / Contract); Medical Research Future Fund (Grant / Contract); Australian Research Council (Independent Contractor ‐ Other); and National Health and Medical Research Council (Grant / Contract).

Update of

  • doi: 10.1002/14651858.CD014713

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References

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    1. Di Pollina L, Guessous I, Petoud V, Combescure C, Buchs B, Schaller P, et al. Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial. BMC Geriatrics 2017;17(1):53. [DOI: 10.1186/s12877-017-0449-9] - DOI - PMC - PubMed
Domingues 2011 {published data only}
    1. Domingues FB, Clausell N, Aliti GB, Dominguez DR, Rabelo ER. Education and telephone monitoring by nurses of patients with heart failure: randomized clinical trial. Arquivos Brasileiros de Cardiologia Imagem Cardiovascular 2011;96(3):233-9. - PubMed
Doris 2014 {published data only}
    1. Yu DS-F, Lee DT, Stewart S, Thompson DR, Choi KC, Yu CM. The effects of a nurse-led empowerment-based disease management program on clinical outcomes, self-care and health-related quality of life among Chinese patients with heart failure. European Journal of Heart Failure 2014;16:60. [DOI: 10.1002/ejhf.93_4] - DOI
Dorr 2008 {published data only}
    1. Dorr DA, Wilcox AB, Brunker CP, Burdon RE, Donnelly SM. The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors. Journal of the American Geriatrics Society 2008;56(12):2195-202. [DOI: 10.1111/j.1532-5415.2008.02005.x] - DOI - PubMed
DRKS00009233 {published data only}
    1. DRKS00009233. Telemedical supported aftercare in the first post-operative year for transplanted patients after living-donor kidney donation, postmortal kidney donation and combined pancreas-/kidney donation. https://drks.de/search/en/trial/DRKS00009233 (first registered 26 August 2015).
DRKS00013199 {published data only}
    1. DRKS00013199. A randomized-controlled multicentre evaluation of an Oncology Nurse Navigator on hospitalization, health outcomes, health care utilization and health care costs. https://drks.de/search/en/trial/DRKS00013199 (first registered 27 October 2017).
Ducharme 2005 {published data only}
    1. Ducharme A, Doyon O, White M, Rouleau JL, Brophy JM. Impact of care at a multidisciplinary congestive heart failure clinic: a randomized trial. Canadian Medical Association Journal 2005;173(1):40-5. - PMC - PubMed
Duflos 2021 {published data only}
    1. Duflos C, Labarre JP, Ologeanu R, Robin M, Cayla G, Galinier M, et al. PRADOC: a trial on the efficiency of a transition care management plan for hospitalized patients with heart failure in France. ESC Heart Failure 2021;8(2):1649-55. [DOI: 10.1002/ehf2.13086] - DOI - PMC - PubMed
Dunagan 2005 {published data only}
    1. Dunagan WC, Littenberg B, Ewald GA, Jones CA, Emery VB, Waterman BM, et al. Randomized trial of a nurse-administered, telephone-based disease management program for patients with heart failure. Journal of Cardiac Failure 2005;11(5):358-65. - PubMed
Eastwood 2019 {published data only}
    1. Eastwood J. Big data evaluation of an integrated care initiative for vulnerable families. International Journal of Integrated Care 2019;19(S1):1-2. [DOI: 10.5334/ijic.s3084] - DOI - PMC - PubMed
Edgren 2016 {published data only}
    1. Edgren G, Anderson J, Dolk A, Torgerson J, Nyberg S, Skau T, et al. "Active health management" can provide support for vulnerable patients. New model for the prevention of unplanned healthcare. Lakartidningen 2016;113:DUEX. - PubMed
Ekdahl 2015 {published data only}
    1. Ekdahl AW, Wirehn AB, Alwin J, Jaarsma T, Unosson M, Husberg M, et al. Costs and effects of an ambulatory geriatric unit (the AGe-FIT Study): a randomized controlled trial. Journal of the American Medical Directors Association 2015;16(6):497-503. [DOI: 10.1016/j.jamda.2015.01.074] - DOI - PubMed
Ell 2007 {published data only}
    1. Ell K, Vourlekis B, Lee PJ, Xie B. Patient navigation and case management following an abnormal mammogram: a randomized clinical trial. Preventive Medicine 2007;44(1):26-33. - PubMed
Ellen 2018 {published data only}
    1. Ellen F, Martina R, Klaus W. Trans-sectional intervention program to improve geriatric care in Regensburg [TIGER]: the transitional care model applied in Germany. European Geriatric Medicine 2018;9:S140. [DOI: 10.1007/s41999-018-0097-4] - DOI
Elseroad 2016 {published data only}
    1. Elseroad S, Seaberg D, Dumas M, Mendiratta S, Whittle J, Holcombe J, et al. Patient navigation for patients frequently visiting the emergency department. Academic Emergency Medicine 2016;23:S220. [DOI: 10.1111/acem.12974] - DOI - PubMed
Enard 2015 {published data only}
    1. Enard KR, Nevarez L, Hernandez M, Hovick SR, Moguel MR, Hajek RA, et al. Patient navigation to increase colorectal cancer screening among Latino Medicare enrollees: a randomized controlled trial. Cancer Causes Control 2015;26(9):1351-9. [DOI: 10.1007/s10552-015-0620-6] - DOI - PMC - PubMed
Englander 2014a {published data only}
    1. Englander H, Michaels L, Chan B, Kansagara D. The care transitions innovation (C-TraIn) for socioeconomically disadvantaged adults: results of a cluster randomized controlled trial. Journal of General Internal Medicine 2014;29(11):1460-7. [DOI: 10.1007/s11606-014-2903-0] - DOI - PMC - PubMed
Englander 2014b {published data only}
    1. Englander H, Michaels L, Chan B, Kansagara D. The care transitions innovation (C-train) for socioeconomically disadvantaged adults, results of a clustered randomized controlled trial. Journal of General Internal Medicine 2014;29:S221. - PMC - PubMed
Entesari‐Tatafi 2017 {published data only}
    1. Entesari-Tatafi D, Stevens J, Hayles R, Bell J, Steinfort C. Telemedicine to deliver personalised health care in chronic obstructive pulmonary disease may reduce hospital admissions. Respirology 2017;22:128. [DOI: 10.1111/resp.13010] - DOI
Fan 2012 {published data only}
    1. Fan VS, Gaziano JM, Lew R, Bourbeau J, Adams SG, Leatherman S, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Annals of Internal Medicine 2012;156(10):673-83. [DOI: 10.7326/0003-4819-156-10-201205150-00003] - DOI - PubMed
Feldman 2018 {published data only}
    1. Feldman CH, Wohlfahrt A, Campos A, Gagne JJ, Iversen MD, Massarotti E, et al. Can patient navigators improve adherence to disease-modifying antirheumatic drugs? Quantitative findings from a six-month single-arm pilot intervention. Arthritis Care & Research 2018;70(9):1400-5. [DOI: 10.1002/acr.23302] - DOI - PubMed
Finkelstein 2020 {published data only}
    1. Finkelstein A, Zhou A, Taubman S, Doyle J. Health care hotspotting - A randomized, controlled trial. New Englan Journal of Medicine 2020;382(2):152-62. [DOI: 10.1056/NEJMsa1906848] - DOI - PMC - PubMed
Finlayson 2018 {published data only}
    1. Finlayson K, Chang AM, Courtney MD, Edwards HE, Parker AW, Hamilton K, et al. Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults. BMC Health Services Research 2018;18(1):956. [DOI: 10.1186/s12913-018-3771-9] - DOI - PMC - PubMed
Fishbane 2017 {published data only}
    1. Fishbane S, Agoritsas S, Bellucci A, Halinski C, Shah HH, Sakhiya V, et al. Augmented nurse care management in CKD Stages 4 to 5: a randomized trial. American Journal of Kidney Diseases 2017;70(4):498-505. [DOI: 10.1053/j.ajkd.2017.02.366] - DOI - PubMed
Foster 2012 {published data only}
    1. Foster SJ, Boyd M, Broad JB, Whitehead N, Kerse N, Lumley T, et al. Aged Residential Care Health Utilisation Study (ARCHUS): a randomised controlled trial to reduce acute hospitalisations from residential aged care. BMC Geriatrics 2012;12:54. [DOI: 10.1186/1471-2318-12-54] - DOI - PMC - PubMed
Freund 2016 {published data only}
    1. Freund T, Peters-Klimm F, Boyd CM, Mahler C, Gensichen J, Erler A, et al. Medical assistant-based care management for high-risk patients in small primary care practices: a cluster randomized clinical trial. Annals of Internal Medicine 2016;164(5):323-30. [DOI: 10.7326/M14-2403] - DOI - PubMed
Gagnon 1999 {published data only}
    1. Gagnon AJ, Schein C, McVey L, Bergman H. Randomized controlled trial of nurse case management of frail older people. Journal of the American Geriatrics Society 1999;47(9):1118-24. - PubMed
Gallo 2023 {published data only}
    1. Gallo LC, Fortmann AL, Clark TL, Roesch SC, Bravin JI, Spierling Bagsic SR, et al. Mi Puente (My Bridge) care transitions program for Hispanic/Latino adults with multimorbidity: results of a randomized controlled trial. Journal of General Internal Medicine 2023;38(9):2098‐106. [DOI: 10.1007/s11606-022-08006-1] - DOI - PMC - PubMed
Gary 2004 {published data only}
    1. Gary TL, Batts-Turner M, Bone LR, Yeh HC, Wang NY, Hill-Briggs F, et al. A randomized controlled trial of the effects of nurse case manager and community health worker team interventions in urban African-Americans with type 2 diabetes. Controlled Clinical Trials 2004;25(1):53-66. - PubMed
Gary 2009 {published data only}
    1. Gary TL, Batts-Turner M, Yeh HC, Hill-Briggs F, Bone LR, Wang NY, et al. The effects of a nurse case manager and a community health worker team on diabetic control, emergency department visits, and hospitalizations among urban African Americans with type 2 diabetes mellitus: a randomized controlled trial. Archives of Internal Medicine 2009;169(19):1788-94. [DOI: 10.1001/archinternmed.2009.338] - DOI - PMC - PubMed
Gellis 2014 {published data only}
    1. Gellis ZD, Kenaley BL, Have TT. Integrated telehealth care for chronic illness and depression in geriatric home care patients: the Integrated Telehealth Education and Activation of Mood (I-TEAM) study. Journal of the American Geriatrics Society 2014;62(5):889-95. [DOI: 10.1111/jgs.12776] - DOI - PubMed
Gilbert 2021 {published data only}
    1. Gilbert T, Occelli P, Rabilloud M, Poupon-Bourdy S, Riche B, Touzet S, et al. A nurse-led bridging program to reduce 30-Day readmissions of older patients discharged from acute care units. Journal of the American Medical Directors Association 2021;22(6):1292-99.e5. [DOI: 10.1016/j.jamda.2020.09.015] - DOI - PubMed
Godwin 2016 {published data only}
    1. Godwin M, Gadag V, Pike A, Pitcher H, Parsons K, McCrate F, et al. A randomized controlled trial of the effect of an intensive 1-year care management program on measures of health status in independent, community-living old elderly: the Eldercare project. Family Practice 2016;33(1):37-41. [DOI: 10.1093/fampra/cmv089] - DOI - PubMed
Goldman 2014 {published data only}
    1. Goldman LE, Sarkar U, Kessell E, Guzman D, Schneidermann M, Pierluissi E, et al. Support from hospital to home for elders: a randomized trial. Annals of Internal Medicine 2014;161(7):472-81. [DOI: 10.7326/M14-0094] - DOI - PubMed
Greineder 1999 {published data only}
    1. Greineder DK, Loane KC, Parks P. A randomized controlled trial of a pediatric asthma outreach program. Journal of Allergy and Clinical Immunology 1999;103(3 Pt 1):436-40. - PubMed
Griswold 2010 {published data only}
    1. Griswold KS, Homish GG, Pastore PA, Leonard KE. A randomized trial: are care navigators effective in connecting patients to primary care after psychiatric crisis? Community Mental Health Journal 2010;46(4):398-402. [DOI: 10.1007/s10597-010-9300-x] - DOI - PubMed
Hanrahan 2014 {published data only}
    1. Hanrahan NP, Solomon P, Hurford MO. A pilot randomized control trial: testing a transitional care model for acute psychiatric conditions. Journal of the American Psychiatric Nurses Association 2014;20(5):315-27. [DOI: 10.1177/1078390314552190] - DOI - PubMed
Hansen 2021 {published data only}
    1. Hansen TK, Pedersen LH, Shahla S, Damsgaard EM, Bruun JM, Gregersen M. Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial. Archives of Gerontology and Geriatrics 2021;97:104511. [DOI: 10.1016/j.archger.2021.104511] - DOI - PubMed
Hastings 2020 {published data only}
    1. Hastings SN, Stechuchak KM, Coffman CJ, Mahanna EP, Weinberger M, Van Houtven CH, et al. Discharge information and support for patients discharged from the Emergency Department: results from a randomized controlled trial. Journal of General Internal Medicine 2020;35(1):79-86. [DOI: 10.1007/s11606-019-05319-6] - DOI - PMC - PubMed
Hengartner 2016 {published data only}
    1. Hengartner MP, Passalacqua S, Heim G, Andreae A, Rossler W, Wyl A. The post-discharge network coordination programme: a randomized controlled trial to evaluate the efficacy of an intervention aimed at reducing rehospitalizations and improving mental health. Frontiers in Psychiatry 2016;7:27. [DOI: 10.3389/fpsyt.2016.00027] - DOI - PMC - PubMed
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    1. Hernandez C, Alonso A, Garcia-Aymerich J, Serra I, Marti D, Rodriguez-Roisin R, et al. Effectiveness of community-based integrated care in frail COPD patients: a randomised controlled trial. NPJ Primary Care Respiratory Medicine 2015;25:15022. [DOI: 10.1038/npjpcrm.2015.22] - DOI - PMC - PubMed
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    1. Hughes SL, Weaver FM, Giobbie-Hurder A, Manheim L, Henderson W, Kubal JD, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA 2000;284(22):2877-85. - PubMed
Ko 2017 {published data only}
    1. Ko FW, Cheung NK, Rainer TH, Lum C, Wong I, Hui DS. Comprehensive care programme for patients with chronic obstructive pulmonary disease: a randomised controlled trial. Thorax 2017;72(2):122-8. [DOI: 10.1136/thoraxjnl-2016-208396] - DOI - PubMed
Koehler 2009 {published data only}
    1. Koehler BE, Richter KM, Youngblood L, Cohen BA, Prengler ID, Cheng D, et al. Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. Journal of Hospital Medicine 2009;4(4):211-8. [DOI: 10.1002/jhm.427] - DOI - PubMed
LaBedz 2022 {published data only}
    1. LaBedz SL, Prieto-Centurion V, Mutso A, Basu S, Bracken NE, Calhoun EA, et al. Pragmatic clinical trial to improve patient experience among adults during transitions from hospital to home: the PArTNER study. Journal of General Internal Medicine 2022;37(16):4103-11. [DOI: 10.1007/s11606-022-07461-0] - DOI - PMC - PubMed
Laramee 2003 {published data only}
    1. Laramee AS, Levinsky SK, Sargent J, Ross R, Callas P. Case management in a heterogeneous congestive heart failure population: a randomized controlled trial. Archives of Internal Medicine 2003;163(7):809-17. - PubMed
Lashley 2019 {published data only}
    1. Lashley C, Taylor SP, Brown R, Burke L, Chou SH, Cunningham K, et al. Structured, proactive care coordination versus usual care for Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS): a pragmatic, randomized controlled trial. Trials 2019;20(1):660. [DOI: 10.1186/s13063-019-3792-7] - DOI - PMC - PubMed
Lasser 2013 {published data only}
    1. Lasser KE, Kenst KS, Quintiliani LM, Wiener RS, Murillo J, Pbert L, et al. Patient navigation to promote smoking cessation among low-income primary care patients: a pilot randomized controlled trial. Journal of Ethnicity in Substance Abuse 2013;12(4):374-90. [DOI: 10.1080/15332640.2013.819311] - DOI - PMC - PubMed
Leavitt 2017 {published data only}
    1. Leavitt MA. The Effect of the Heart Failure Nurse Navigator on 30-Day Hospital Readmissions of Older Adults [Dissertation]. Boca Raton (FL): Florida Atlantic University, 2017.
Leung 2004 {published data only}
    1. Leung AC, Yau DC, Liu CP, Yeoh CS, Chui TY, Chi I, et al. Reducing utilisation of hospital services by case management: a randomised controlled trial. Australian Health Review 2004;28(1):79-86. - PubMed
Li 2013a {published data only}
    1. Li CY, Lee CY, Chang Lee SN, Liao WC, Chen YJ. The effectiveness of case management for patients with heart filure. Macau Journal of Nursing 2013;12(1):35-41.
Li 2013b {published data only}
    1. Li CY, Lee CY, Chang Lee SN, Liao WC, Chen YJ. The effectiveness of case management for patients with heart failure. Macau Journal of Nursing 2013;12(1):35-41.
Liang 2021 {published data only}
    1. Liang HY, Hann LL, Yu CC, Mei WF, Yu S. Effectiveness of a nurse‐led tele‐homecare program for patients with multiple chronic illnesses and a high risk for readmission: a randomized controlled trial. Journal of Nursing Scholarship 2021;53(2):161-70. [DOI: 10.1111/jnu.12622] - DOI - PubMed
Mann 2021 {published data only}
    1. Mann J, Thompson F, McDermott R, Esterman A, Strivens E. Impact of an integrated community-based model of care for older people with complex conditions on hospital emergency presentations and admissions: a step-wedged cluster randomized trial. BMC Health Services Research 2021;21(1):701. [DOI: 10.1186/s12913-021-06668-x] - DOI - PMC - PubMed
Meisinger 2013 {published data only}
    1. Meisinger C, Stollenwerk B, Kirchberger I, Seidl H, Wende R, Kuch B, et al. Effects of a nurse-based case management compared to usual care among aged patients with myocardial infarction: results from the randomized controlled KORINNA study. BMC Geriatrics 2013;13:115. [DOI: 10.1186/1471-2318-13-115] - DOI - PMC - PubMed
Metsch 2016 {published data only}
    1. Metsch LR, Feaster DJ, Gooden L, Matheson T, Stitzer M, Das M, et al. Effect of patient navigation with or without financial incentives on viral suppression among hospitalized patients with HIV infection and substance use: a randomized clinical trial. JAMA 2016;316(2):156-70. [DOI: 10.1001/jama.2016.8914] - DOI - PMC - PubMed
Mizukawa 2019 {published data only}
    1. Mizukawa M, Moriyama M, Yamamoto H, Rahman MM, Naka M, Kitagawa T, et al. Nurse-led collaborative management using telemonitoring improves quality of life and prevention of rehospitalization in patients with heart failure. International Heart Journal 2019;60(6):1293-302. [DOI: 10.1536/ihj.19-313] - DOI - PubMed
Moschetti 2015 {published data only}
    1. Moschetti K, Iglesias K, Baggio S, Velonaki V-S, Ruggeri O, Hugli O, et al. Potential health-care service utilization substitution effects induced by case management for emergency department frequent users. Journal of General Internal Medicine 2015;30:S230.
Navaneethan 2017 {published data only}
    1. Navaneethan SD, Jolly SE, Schold JD, Arrigain S, Nakhoul G, Konig V, et al. Pragmatic randomized, controlled trial of patient navigators and enhanced personal health records in CKD. Clinical Journal of the American Society of Nephrology 2017;12(9):1418-27. [DOI: 10.2215/CJN.02100217] - DOI - PMC - PubMed
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    1. Naylor MD, McCauley KM. The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions. Journal of Cardiovascular Nursing 1999;14(1):44‐54. [DOI: 10.1097/00005082-199910000-00006] - DOI - PubMed
Naylor 2022 {published data only}
    1. Naylor MD, Hirschman KB, McCauley K, Shaid EC, Hanlon AL, Whitehouse CR, et al. Mirror-TCM: multisite replication of a randomized controlled trial – transitional care model. Contemporary Clinical Trials 2022;112:106620. [DOI: 10.1016/j.cct.2021.106620] - DOI - PubMed
Occelli 2016 {published data only}
    1. Occelli P, Touzet S, Rabilloud M, Ganne C, Poupon Bourdy S, et al. Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial. BMC Geriatrics 2016;16:57. [DOI: 10.1186/s12877-016-0233-2] - DOI - PMC - PubMed
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Oliva 2008 {published data only}
    1. Oliva NL. The Impact of RN Case Management on Inpatient and ED Utilization in a Chronically Ill, Older Adult, Community-Dwelling Population [Dissertation]. San Francisco: University of California, 2008.
Pantell 2020 {published data only}
    1. Pantell MS, Hessler D, Long D, Alqassari M, Schudel C, Laves E, et al. Effects of in-person navigation to address family social needs on child health care utilization: a randomized clinical trial. JAMA Network Open 2020;3(6):e206445. [DOI: 10.1001/jamanetworkopen.2020.6445] - DOI - PMC - PubMed
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    1. Parsons M, Parsons J, Rouse P, Pillai A, Mathieson S, Parsons R, et al. Supported discharge teams for older people in hospital acute care: a randomised controlled trial. Age and Ageing 2018;47(2):288-94. [DOI: 10.1093/ageing/afx169] - DOI - PubMed
Patricia 2020 {published data only}
    1. Patricia J, Verweij L, Buurman B, Terbraak M, Daliri S, Latour C, et al. Effect of nurse-coordinated transitional care in high risk older cardiac patients: the cardiac care bridge randomized clinical trial. European Geriatric Medicine 2020;11(SUPPL 1):S115. [DOI: 10.1007/s41999-020-00428-6] - DOI
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    1. Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 2009;301(6):603-18. [DOI: 10.1001/jama.2009.126] - DOI - PubMed
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    1. Pevnick JM, Keller MS, Kennelty KA, Nuckols TK, Ko EM, Amer K, et al. The Pharmacist Discharge Care (PHARM-DC) study: a multicenter RCT of pharmacist-directed transitional care to reduce post-hospitalization utilization. Contemporary Clinical Trials 2021;106:106419. [DOI: 10.1016/j.cct.2021.106419] - DOI - PMC - PubMed
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    1. Plant NA, Kelly PJ, Leeder SR, D'Souza M, Mallitt KA, Usherwood T, et al. Coordinated care versus standard care in hospital admissions of people with chronic illness: a randomised controlled trial. Medical Journal of Australia 2015;203(1):33-8. - PubMed
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Pusateri 2023 {published data only}
    1. Pusateri A, Litzenberg K, Griffiths C, Hayes C, Gnyawali B, Manious M, et al. Randomized intervention and outpatient follow-up lowers 30-d readmissions for patients with hepatic encephalopathy, decompensated cirrhosis. World Journal of Hepatology 2023;15(6):826‐40. [DOI: 10.4254/wjh.v15.i6.826] - DOI - PMC - PubMed
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    1. Raftery JP, Addington-Hall JM, MacDonald LD, Anderson HR, Bland JM, Chamberlain J, et al. A randomized controlled trial of the cost-effectiveness of a district co-ordinating service for terminally ill cancer patients. Palliative Medicine 1996;10(2):151-61. - PubMed
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    1. Rea HH, Kenealy TW, Rolland T-M, Naumann C, Hou T, Sheridan N. Enabling integrated health and care. International Journal of Integrated Care 2016;16(6):1-3. [DOI: 10.5334/ijic.2674] - DOI
Reuland 2017 {published data only}
    1. Reuland DS, Brenner AT, Hoffman R, McWilliams A, Rhyne RL, Getrich C, et al. Effect of combined patient decision aid and patient navigation vs usual care for colorectal cancer screening in a vulnerable patient population: a randomized clinical trial. JAMA Internal Medicine 2017;177(7):967-74. [DOI: 10.1001/jamainternmed.2017.1294] - DOI - PMC - PubMed
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Saltbaek 2024 {published data only}
    1. Saltbaek L, Bidstrup PE, Karlsen RV, Hoeg BL, Horsboel TA, Belmonte F, et al. Nurse-led individualized follow-up versus regular physician-led visits after early breast cancer (MyHealth): a phase III randomized, controlled trial. Journal of Clinical Oncology 2024;42(17):2038-49. [DOI: 10.1200/JCO.23.01447] - DOI - PubMed
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    1. Schnipper JL, Samal L, Nolido N, Yoon C, Dalal AK, Magny-Normilus C, et al. The effects of a multifaceted intervention to improve care transitions within an accountable care organization: results of a stepped-wedge cluster-randomized trial. Journal of Hospital Medicine 2021;16(1):15-22. [DOI: 10.12788/jhm.3513] - DOI - PMC - PubMed
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