The effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review

Multidimensional frailty as a predictor of mortality among older adults: a systematic review and meta-analysis

OBJECTIVE

This systematic review examined studies that assessed the relationship between mortality risk and multidimensional frailty. The pooled risk of mortality was estimated via a meta-analysis.

DESIGN

A systematic review and meta-analysis.

METHODS

A systematic search for potentially eligible literature was conducted on January 2, 2023, using five electronic databases: Web of Science, CINAHL, PubMed, the Cochrane Library and Embase. This review included cohort or longitudinal studies examining the association between multidimensional frailty/prefrailty and mortality in older adults. The quality of the included studies was evaluated via the Quality in Prognosis Studies (QUIPS) tool. Two independent researchers identified eligible studies and extracted the data. The data analyses were performed via STATA, version 15.0.

RESULTS

A total of 24 studies with 34,664 participants were included. The 24 studies were published between 2012 and 2022, with most studies being performed in Italy (n = 16). The sample sizes of the included studies ranged from 71 to 12,020. Most included studies were conducted in hospital settings. The QUIPS bias assessment results showed that the most frequent source of potential bias was study confounding. The meta-analysis results showed that multidimensional frailty was a significant predictor of mortality (HR = 5.48, 95% CI = 3.91-7.67, p < 0.001). In addition, multidimensional prefrailty was also a significant predictor of mortality (HR = 2.56, 95% CI = 2.17-3.02, p < 0.001). The results of the meta-analysis using the ORs revealed that multidimensional frailty was a risk factor for mortality in older people (OR = 4.59, 95% CI = 2.47-8.55, p < 0.05).

CONCLUSIONS AND IMPLICATIONS

This systematic review of the relationship between multidimensional frailty and mortality found that multidimensional frailty/prefrailty is a predictor of mortality. More studies should be conducted in community dwelling populations and nursing homes.

Interventions to minimise hospital winter pressures related to discharge planning and integrated care: a rapid mapping review of UK evidence

Background

Winter pressures are a familiar phenomenon within the National Health Service and represent the most extreme of many regular demands placed on health and social care service provision. This review focuses on a part of the pathway that is particularly problematic: the discharge process from hospital to social care and the community. Although studies of discharge are plentiful, we identified a need to focus on identifying interventions and initiatives that are a specific response to 'winter pressures'. This mapping review focuses on interventions or initiatives in relation to hospital winter pressures in the United Kingdom with either discharge planning to increase smart discharge (both a reduction in patients waiting to be discharged and patients being discharged to the most appropriate place) and/or integrated care.

Methods

We conducted a mapping review of United Kingdom evidence published 2018-22. Initially, we searched MEDLINE, Health Management Information Consortium, Social Care Online, Social Sciences Citation Index and the King's Fund Library to find relevant interventions in conjunction with winter pressures. From these interventions we created a taxonomy of intervention types and a draft map. A second broader stage of searching was then undertaken for named candidate interventions on Google Scholar (Google Inc., Mountain View, CA, USA). For each taxonomy heading, we produced a table with definitions, findings from research studies, local initiatives and systematic reviews and evidence gaps.

Results

The taxonomy developed was split into structural, changing staff behaviour, changing community provision, integrated care, targeting carers, modelling and workforce planning. The last two categories were excluded from the scope. Within the different taxonomy sections we generated a total of 41 headings. These headings were further organised into the different stages of the patient pathway: hospital avoidance, alternative delivery site, facilitated discharge and cross-cutting. The evidence for each heading was summarised in tables and evidence gaps were identified.

Conclusions

Few initiatives identified were specifically identified as a response to winter pressures. Discharge to assess and hospital at home interventions are heavily used and well supported by the evidence but other responses, while also heavily used, were based on limited evidence. There is a lack of studies considering patient, family and provider needs when developing interventions aimed at improving delayed discharge. Additionally, there is a shortage of studies that measure the longer-term impact of interventions. Hospital avoidance and discharge planning are whole-system approaches. Considering the whole health and social care system is imperative to ensure that implementing an initiative in one setting does not just move the problem to another setting.

Limitations

Time limitations for completing the review constrained the period available for additional searches. This may carry implications for the completeness of the evidence base identified.

Future work

Further research to consider a realist review that views approaches across the different sectors within a whole system evaluation frame.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130588) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 31. See the NIHR Funding and Awards website for further award information.

Rurality and patients' hospital experience: A multisite analysis from a US healthcare system

BACKGROUND

The association between rurality of patients' residence and hospital experience is incompletely described. The objective of the study was to compare hospital experience by rurality of patients' residence.

METHODS

From a US Midwest institution's 17 hospitals, we included 56,685 patients who returned a post-hospital Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. We defined rurality using rural-urban commuting area codes (metropolitan, micropolitan, small town, rural). We evaluated the association of patient characteristics with top-box score (favorable response) for 10 HCAHPS items (six composite, two individual, two global). We obtained adjusted odds ratios (aOR [95% CI]) from logistic regression models including patient characteristics. We used key driver analysis to identify associations between HCAHPS items and global rating (combined overall rating of hospital and recommend hospital).

RESULTS

Of all items, overall rating of hospital had lower odds of favorable response for patients from metropolitan (0.88 [0.81-0.94]), micropolitan (0.86 [0.79-0.94]), and small towns (0.90 [0.82-0.98]) compared with rural areas (global test, P = .003). For five items, lower odds of favorable response was observed for select areas compared with rural; for example, recommend hospital for patients from micropolitan (0.88 [0.81-0.97]) but not metropolitan (0.97 [0.89-1.05]) or small towns (0.93 [0.85-1.02]). For four items, rurality showed no association. In metropolitan, micropolitan, and small towns, men vs. women had higher odds of favorable response to most items, whereas in rural areas, sex-based differences were largely absent. Key driver analysis identified care transition, communication about medicines and environment as drivers of global rating, independent of rurality.

CONCLUSIONS

Rural patients reported similar or modestly more favorable hospital experience. Determinants of favorable experience across rurality categories may inform system-wide and targeted improvement.

Patient outcomes after implementation of transitional care protocols in elective neurosurgery: a systematic review and meta-analysis

OBJECTIVE

30-day readmissions are a significant burden on the healthcare system. Postoperative transitional care protocols (TCPs) for safe and efficient discharge planning are being more widely adopted to reduce readmission rates. Currently, little evidence exists to justify the utility of TCPs for improving patient outcomes in elective neurosurgery. The objective of this systematic review was to determine the extent to which TCPs reduce adverse outcomes in patients undergoing elective neurosurgical procedures.

MATERIALS AND METHODS

A systematic review and meta-analysis was conducted after PROSPERO registration. Pubmed, Embase, and Cochrane review databases were searched through February 1, 2024. Keywords included: "transitional care AND neurosurgery", "Discharge planning AND neurosurgery". Articles were included if they assessed postoperative TCPs in an adult population undergoing elective neurosurgeries. Exclusion criteria were pediatric patients, implementation of Enhanced Recovery After Surgery (ERAS) protocols, or non-elective neurosurgical procedures. The primary outcome was readmission rates after implementation of TCPs.

RESULTS

16 articles were included in this review. 2 articles found that patients treated with TCPs had significantly higher chances of home discharge. 7 articles found a significant association between implementation of TCP and reduced length of stay and intensive care unit stay. 3 articles reported an increase in patient satisfaction after implementation of TCPs. 3 found that TCP led to a significant decrease in readmissions. After meta-analysis, TCPs were associated with significantly decreased readmission rates (OR: 0.68, p < 0.0001), length of stay (mean difference: -0.57, p < 0.00001), and emergency department visits (OR: 0.33, p < 0.0001).

CONCLUSIONS

This systematic review and meta-analysis found that an overwhelming majority of the available literature supports the effectiveness of discharge planning on at least one measure of patient outcomes. However, the extent to which each facet of the TCP affects outcomes in elective neurosurgery remains unclear. Future efforts should be made to compare the effectiveness of different TCPs.

Factors associated with malnutrition among older people in Swedish short-term care: Poor oral health, dysphagia and mortality

OBJECTIVES

To investigate the relationship between malnutrition and potential contributing factors such as poor oral health, dysphagia and mortality among older people in short-term care.

METHODS

This cross-sectional study is a part of the multidisciplinary multicentre project SOFIA (Swallowing function, Oral health and Food Intake in old Age), which includes older people (≥65 years) in 36 short-term care units in five regions of Sweden. Nutritional status was measured with version II of the Minimal Eating Observation and Nutrition Form (MEONF-II), oral health with the Revised Oral Assessment Guide (ROAG), dysphagia with a water swallow test, and the mortality rate was followed for 1 year. Data were analysed using descriptive analysis and logistic regression models to calculate odds ratios for the association between malnutrition and these factors.

RESULTS

Among the 391 participants, the median age was 84 years and 53.3% were women. Mortality rate was 25.1% within 1 year in the total group, and was higher among malnourished participants than among their well-nourished counterparts. Severe dysphagia (OR: 6.51, 95% CI: 2.40-17.68), poor oral health (OR: 5.73, 95% CI: 2.33-14.09) and female gender (OR: 2.2, 95% CI: 1.24-3.93) were independently associated with malnutrition.

CONCLUSION

Mortality rate was higher among malnourished people than those who were well nourished. Severe dysphagia, poor oral health and female gender was predictors of malnutrition among older people in short-term care. These health risks should be given more attention in short-term care with early identification.

Could it have been predicted? A retrospective analysis of the last year of life for people who died whilst in an intermediate care centre

Objectives

Intermediate care centres (ICCs) exist in the UK to bridge between acute hospital and home for those with rehabilitation needs. A national study shows 25% of ICC in-patients died within a year of admission. High quality end-of-life care includes early conversations with a person and their loved ones about what matters to them; timely identification of those who are likely to be nearing the end of their life is key.

Methods

This retrospective quantitative review of 98 patient notes reviewed deaths in one NHS trust, comparing 50 deaths in the acute hospital and 48 in the ICC. Data included frailty score, previous hospital admissions, specialist palliative input and conversations between professionals, patients and their loved ones. Supportive and Palliative Care Indicators Tool (SPICT) scores were used to identify those likely to have a poor prognosis.

Results

Results showed statistically significant differences between the groups. The ICC cohort were older with higher clinical frailty scores. They were less likely to have previous hospital admissions but more likely to have poor prognostic features on final admission. Despite this, the possibility of deterioration was discussed them less frequently than the acute hospital cohort, and fewer saw the Palliative care team.

Conclusion

This data suggests support is needed in ICCs to recognise those likely to be nearing end-of-life. One challenge is patients are more likely to be seen as 'well' in a rehabilitation focused environment. This paper suggests a 'proactive approach' trial using SPICT for ongoing assessment of ICC in-patients supporting identification of a deteriorating person and avoid missed opportunities for key conversations.

Exploring home rehabilitation therapists' experiences of supporting older persons to physical exercise after acute hospitalization: a qualitative interview study

PURPOSE

After hospitalization, older persons may face a decline in physical function and daily independence. In-hospital exercise interventions can mitigate this decline, and continued support from primary healthcare post-discharge may enhance sustainability. This study aimed to explore home rehabilitation therapists' experiences of supporting physical exercise after acute hospitalization, including exercise programs initiated during hospital stay.

METHODS

This qualitative study was conducted alongside a randomized-controlled trial to investigate prerequisites for a transitional care intervention. Twelve interviews were conducted with physiotherapists, occupational therapists, and managers across seven rehabilitation therapy services in Stockholm, Sweden. Data were analyzed using reflexive thematic analysis.

RESULTS

The analysis generated the theme Striving for individualized support for physical exercise, although limited resources and a fragmented home care risk to direct support away from those who need it the most. It was based on four subthemes: The starting point is always the patient's current needs, goals, and prerequisites, Continuing the exercise initiated during hospitalization by adapting it to the patient's situation at home, Work premises not tailored to patients with complex care needs, and A home care organization that lacks coordination and unified purpose.

CONCLUSIONS

Interventions supporting older persons to physical exercise after acute hospitalization need to be tailored to the individual, support motivation, and be adapted to the patient's home situation. Challenges may arise when care recourses lack alignment with the patients' needs, and when the collaboration among care providers is limited. The findings contribute valuable insights for future studies incorporating transitional care interventions in similar context.

Validation and Clinical Application of the Japanese Version of the Patient-Reported Experience Measures for Intermediate Care Services: A Cross-Sectional Study

Older adult patients account for 70% of all hospitalized patients in Japan, and intermediate care based on patient-centered care (PCC) that ensures continuity and quality of care at the interface between home services and acute care services and restores patient's independence and confidence is necessary for them to continue living independently. At present, no concept of intermediate care is established in Japan, and the implementation of PCC has been delayed. Thus, in this study, a Japanese version of the intermediate care evaluation index (patient-reported experience measure (PREM)) was created on the basis of the original PREM developed in the UK, and data in wards with intermediate care functions in Japan were collected to confirm internal consistency and validity from 2020 to 2022. The Japanese version of PREM was found to have a factor structure with two potential factors. Given the clear correlation with the shared decision-making evaluation index, which is the pinnacle of PCC, the theoretical validity of the Japanese version of PREM, which is based on PCC as a theoretical basis, was confirmed.

The PRO-HOME Project. A multicomponent intervention for the protected discharge from the hospital of multimorbid and polytreated older individuals by using innovative technologies: A pilot study

BACKGROUD

Discharge planning from the hospital of frail older patients is an important step to avoid inappropriate long-stay hospitalizations and to prevent the risks related to the prolonged hospitalization. In this frame, we developed an experimental trial-'PRO-HOME', a multicomponent programme of interventions for multimorbid and polytreated hospitalized older patients.

AIM

The main aim of the study was to develop a protected discharge facility using a mini apartment equipped with advanced architectural and technological components to reduce the length of hospital stay of older participants (aged 65+ years old) admitted to the hospital for an acute event, deemed stable and dischargeable.

MATERIALS AND METHODS

This is a pilot randomized controlled study, comparing 30 hospitalized participants included in a multidimensional, transitional care programme based on information and communication technologies to 30 patients in standard usual care until hospital discharge.

RESULTS

We presented the study design of the PRO-HOME programme, including architectural and technological components, the enrolment procedures, the components of the intervention that is physical activity, cognitive training and life-style education and the evaluation method of the intervention based on the Comprehensive Geriatric Assessment to explore the changes in the individual domains that are target of the multicomponent intervention.

CONCLUSIONS

The final results will suggest whether the PRO-HOME programme represents a useful and feasible intervention to reduce the length of hospital stay of multimorbid and polytreated hospitalized older patients and improve their physical and cognitive performances and overall quality of life.

PATIENT OR PUBLIC CONTRIBUTION

Due to the characteristics of the population of interest of the PRO-HOME study, we involved in the study design and programme of the activities the participants enrolled in a previous smart home-based project named MoDiPro carried-out during a 3-year period. The elderly participants from the local population involved were asked, by means of focus groups, for feedback on their experience in MoDiPro, and their suggestions were integrated into the design phase of the current PRO-HOME project. The focus groups included open group interviews with a qualitative collection of the patients' feedback so that the participants could interact with each other.

Reduced Readmission and Increased Patient Satisfaction in Post-Cardiac Arrhythmia Ablation: A Randomized Pilot Study

BACKGROUND

Hospital readmissions within 30 days post-cardiac arrhythmia ablation are typically related to postoperative complications and arrhythmia recurrence and considered mostly preventable.

PURPOSE

To evaluate the impact of a cardiac ablation patient education program on hospital readmissions and patient satisfaction.

METHODS

An education intervention was established for patients who underwent cardiac ablation based on the Project RED framework. Hospital readmissions rates 30 days postprocedure and satisfaction via a single-blinded posttest design were assessed to evaluate the program.

RESULTS

Those in the intervention group had a significantly lower rate of 30-day readmissions (7.1% vs 53.3%, P = .014). A large magnitude of effect and higher total patient satisfaction scores were also seen in the intervention group ( M = 633, SD = 78) than in the control group ( M = 508, SD = 137, P = .005).

CONCLUSIONS

Results of this study support the implementation of an enhanced cardiac arrhythmia patient education intervention with consideration of identified facilitators and barriers.

Do critical illness survivors with multimorbidity need a different model of care?

There is currently a lack of evidence on the optimal strategy to support patient recovery after critical illness. Previous research has largely focussed on rehabilitation interventions which aimed to address physical, psychological, and cognitive functional sequelae, the majority of which have failed to demonstrate benefit for the selected outcomes in clinical trials. It is increasingly recognised that a person's existing health status, and in particular multimorbidity (usually defined as two or more medical conditions) and frailty, are strongly associated with their long-term outcomes after critical illness. Recent evidence indicates the existence of a distinct subgroup of critical illness survivors with multimorbidity and high healthcare utilisation, whose prior health trajectory is a better predictor of long-term outcomes than the severity of their acute illness. This review examines the complex relationships between multimorbidity and patient outcomes after critical illness, which are likely mediated by a range of factors including the number, severity, and modifiability of a person's medical conditions, as well as related factors including treatment burden, functional status, healthcare delivery, and social support. We explore potential strategies to optimise patient recovery after critical illness in the presence of multimorbidity. A comprehensive and individualized approach is likely necessary including close coordination among healthcare providers, medication reconciliation and management, and addressing the physical, psychological, and social aspects of recovery. Providing patient-centred care that proactively identifies critical illness survivors with multimorbidity and accounts for their unique challenges and needs is likely crucial to facilitate recovery and improve outcomes.

Evaluating step-down, intermediate care programme in Buckinghamshire, UK: a mixed methods study

BACKGROUND

Intermediate care (IC) services are models of care that aim to bridge the gap between hospital and home, enabling continuity of care and the transition to the community. The purpose of this study was to explore patient experience with a step-down, intermediate care unit in Buckinghamshire, UK.

METHODS

A mixed-methods study design was used. Twenty-eight responses to a patient feedback questionnaire were analysed and seven qualitative semi-structured interviews were conducted. The eligible participants were patients who had been admitted to the step-down IC unit. Interview transcripts were analysed using thematic analysis.

FINDINGS

Our interview data generated five core themes: (1) "Being uninformed", (2) "Caring relationships with health practitioners", (3) "Experiencing good intermediate care", (4) "Rehabilitation" and (5) "Discussing the care plan". When comparing the quantitative to the qualitative data, these themes are consistent.

CONCLUSIONS

Overall, the patients reported that the admission to the step-down care facility was positive. Patients highlighted the supportive relationship they formed with healthcare professionals in the IC and that the rehabilitation that was offered in the IC service was important in increasing mobility and regaining their independence. In addition, patients reported that they were largely unaware about their transfer to the IC unit before this occurred and they were also unaware of their discharge package of care. These findings will inform the evolving patient-centred journey for service development within intermediate care.

Effectiveness of community hospital post-acute care on mortality, re-admission, institutionalization, and activation of a home care programme in Emilia-Romagna region, Italy

BACKGROUND

In Italy, there is scant evidence on the impact of Community Hospitals (CHs) on clinical outcomes.

AIMS

To assess the effectiveness of CHs versus long-term care hospital or inpatient rehabilitation facilities on mortality, re-admission, institutionalization, and activation of a home care programme in the Emilia-Romagna Region (ERR-Italy) after acute hospitalisation.

METHODS

We implemented a cohort study drawing upon the ERR Administrative Healthcare Database System and including hospital episodes of ERR residents subject ≥ 65 years, discharged from a public or private hospital with a medical diagnosis to a CH or to usual care between 2017 and 2019. To control for confounding, we applied a propensity score matching.

RESULTS

Patients transferred to CHs had a significantly lower risk of dying but an increased risk of being readmitted to community or acute hospital within 30/90 days from discharge. The hazard of institutionalisation within 30/90 days was significantly lower in the whole population of the CH exposed group but not among patients with cardiac or respiratory chronic diseases or diabetes. The activation of a home care program within 90 days was slightly higher for those who were transferred to a CH.

DISCUSSION

The findings of our study show mixed effects on outcomes of patients transferred to CHs compared to those who followed the post-acute usual care and should be taken with cautious as could be affected by the so-called 'confounding by indication'.

CONCLUSIONS

The study contributes to the intermediate care available evidence from a region with a well-established care provision through CHs.

Prolonged stay at an acute-care hospital in Israel among older adults awaiting transfer to post-acute care: retrospective study on risk factors and consequences

BACKGROUND

Older adults frequently experience deconditioning following acute illnesses and require discharge from acute-care facilities to post-acute care facilities, which are limited. Our study aimed to explore predictors and outcomes associated with elongated length of stay (LOS) among older adults awaiting discharge to skilled nursing facility (SNF).

METHODS

Retrospective cohort study was conducted at Shamir Medical Center, Israel, among adults (> 65 years) eligible for SNF. ROC curve analysis was used to determine prolonged LOS based on the risk to fall. Logistic and Cox regressions were used to analyze predictors and outcomes.

RESULTS

Among 659 older adults awaiting transfer to SNF, 127 patients (24% among survivors of the index hospitalization) had prolonged LOS (> 12 days). The median age of patients was 82 years and 51% were females. The independent predictors for prolonged LOS were lower Norton index, higher MUST score, and admission from home. Prolonged LOS was independently associated with hospital-acquired infections, device related infections, and acquisitions of multidrug-resistant organisms.

CONCLUSION

Prolonged LOS among older adults, awaiting transfer to SNF, should be suspected among non-institutionalized older adults with lower nutritional status and higher risk of pressure ulcers. The burden associated with establishing additional SNF beds, must be outweighed vs. the substantial infectious complications among awaiting older adults.

Transitional Care for Patients With Portal Hypertension: A Multicenter Study of Intervention for Post-TIPS Patients

To explore the application effect of transitional nursing in patients with TIPS. A total of 368 patients were allocated to control group (conventional care) and intervention group (conventional care combined with transitional care). The Child-Pugh scores, blood ammonia levels, compliance behavior, medication compliance, and adverse event incidence rates were compared at 1, 3, 6, 9, and 12 months post-TIPS. There were significant differences in compliance behavior scores, Child-Pugh scores for group effects, time effects, and group × time interaction between the two groups at 1, 3, 6, 9, and 12 months post-TIPS, significant differences in blood ammonia levels at 9 months, and incidence of postoperative adverse events at 12 months after TIPS. Post-TIPS transitional care interventions increased patients' access to scientifically informed nursing, significantly improved patients' compliance behavior and health and decreased the incidence of postoperative adverse events.

‘Is my journey destination home?’ Exploring the experiences of older adults who undertake a transition care programme: a qualitative study

Transition care programmes (TCP) provide older adults with goal-oriented rehabilitation after hospitalisation. However, limited research has focused on understanding older adults' experiences when undertaking TCP. Using a phenomenological approach, we explored the lived experience of older adults undertaking a TCP at a transition care facility in Australia. A purposive sample (N = 33 participants: 16 older adults, four family members and 13 staff) was recruited. Semi-structured interviews were undertaken at three time-points during admission and inductive thematic analysis was utilised. Older adults reflected on their TCP experiences through an emotional lens through which they deliberated, ‘is my destination home?’ Fear of losing independence and uncertainty about their discharge destination strongly influenced older adults' perspectives regarding their TCP experience. Emotional responses, both positive and negative, were influenced by expectations prior to admission, level of family support and staff behaviour. Staff and family concurred that many older adults were confused about their admission to the facility and initially were unprepared to engage in the rehabilitation provided. Older adults experienced TCP as a time of great uncertainty and feared the unknown when discharged from hospital to transition care. They expressed grief at the loss of existing life roles and anxiety about the possibility of being unable to return home. Health professionals need to inform and tailor rehabilitation for older adults to better support this transient time of life.

Balancing standardisation and individualisation in transitional care pathways: a meta-ethnography of the perspectives of older patients, informal caregivers and healthcare professionals

BACKGROUND

Transitional care implies the transfer of patients within or across care settings in a seamless and safe way. For frail, older patients with complex health issues, high-quality transitions are especially important as these patients typically move more frequently within healthcare settings, requiring treatment from different providers. As transitions of care for frail people are considered risky, securing the quality and safety of these transitions is of great international interest. Nevertheless, despite efforts to improve quality in transitional care, research indicates that there is a lack of clear guidance to deal with practical challenges that may arise. The aim of this article is to synthesise older patients, informal caregivers and healthcare professionals' experiences of challenges to achieving high-quality transitional care.

METHODS

We used the seven-step method for meta-ethnography originally developed by Noblit and Hare. In four different but connected qualitative projects, the authors investigated the challenges to transitional care for older people in the Norwegian healthcare system from the perspectives of older patients, informal caregivers and healthcare professionals. In this paper, we highlight and discuss the cruciality of these challenging issues by synthesising the results from twelve articles.

RESULTS

The analysis resulted in four themes: i) balancing person-centred versus efficient care, ii) balancing everyday patient life versus the treatment of illness, iii) balancing user choice versus "What Matters to You", and iv) balancing relational versus practical care. These expressed challenges represent tensions at the system, organisation and individual levels based on partial competing assumptions on person-centred-care-inspired individualisation endeavours and standardisation requirements in transitional care.

CONCLUSIONS

There is an urgent need for a clearer understanding of the tension between standardisation and individualisation in transitional care pathways for older patients to ensure better healthcare quality for patients and more realistic working environments for healthcare professionals. Incorporating a certain professional flexibility within the wider boundary of standardisation may give healthcare professionals room for negotiation to meet patients' individual needs, while at the same time ensuring patient flow, equity and evidence-based practice.

After Hospital: Should Older Care-Needing Patients Be Transferred to Their Homes or to an Intermediate Care Institution?

BACKGROUND

In most European countries, communities need to provide health and social care services to an increasing number of severely ill patients discharged from hospitals. We investigated whether nurses in hospitals and in the communities' health and social care services experienced that the administration in the municipalities allocated older patients the right type of services after hospital discharge.

METHODS

We used data from Norway, with a qualitative pilot study and quantitative analysis (structural equation modeling) of surveys involving 2431 nurses on inpatient wards in acute hospitals and 4312 nurses working in nursing homes or home nursing.

RESULTS

Dissatisfaction was widespread with the use of patients' homes the first days after hospital discharge. Among nurses working in hospitals, 38% were commonly or very commonly disagreeing with the use of the patient's home after hospital discharge, 25% among home nurses, and 18% among nurses in nursing homes. Home nurses were more prone to oppose the use of patients' homes if they also experienced that their service had inadequate staffing or inadequate medical equipment.

CONCLUSIONS

This research indicates conflicting priorities between the bureaucracy and nurses involved in actual work with older patients. From the nurses' perspective, the municipalities' administration was offering too few older patients short-term-stay in an intermediate care institution as part of the clinical pathway from hospital to home. However, providing more recourses to home nursing would improve their ability to provide sufficient care to older patients discharged from hospital.

Discharge planning from hospital

BACKGROUND

Discharge planning is a routine feature of health systems in many countries that aims to reduce delayed discharge from hospital, and improve the co-ordination of services following discharge from hospital and reduce the risk of hospital readmission. This is the fifth update of the original review.

OBJECTIVES

To assess the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two trials registers on 20 April 2021. We searched two other databases up to 31 March 2020. We also conducted reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomised trials that compared an individualised discharge plan with routine discharge that was not tailored to individual participants. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies by older people with a medical condition, people recovering from surgery, and studies that recruited participants with a mix of conditions. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data it was not possible because of differences in the reporting of outcomes, we summarised the reported results for each trial in the text.

MAIN RESULTS

We included 33 trials (12,242 participants), four new trials included in this update. The majority of trials (N = 30) recruited participants with a medical diagnosis, average age range 60 to 84 years; four of these trials also recruited participants who were in hospital for a surgical procedure. Participants allocated to discharge planning and who were in hospital for a medical condition had a small reduction in the initial hospital length of stay (MD - 0.73, 95% confidence interval (CI) - 1.33 to - 0.12; 11 trials, 2113 participants; moderate-certainty evidence), and a relative reduction in readmission to hospital over an average of three months follow-up (RR 0.89, 95% CI 0.81 to 0.97; 17 trials, 5126 participants; moderate-certainty evidence). There was little or no difference in participant's health status (mortality at three- to nine-month follow-up: RR 1.05, 95% CI 0.85 to 1.29; 8 trials, 2721 participants; moderate certainty) functional status and psychological health measured by a range of measures, 12 studies, 2927 participants;  low certainty evidence). There was some evidence that satisfaction might be increased for patients (7 trials), caregivers (1 trial) or healthcare professionals (2 trials) (very low certainty evidence). The cost of a structured discharge plan compared with routine discharge is uncertain (7 trials recruiting 7873 participants with a medical condition; very low certainty evidence).

AUTHORS' CONCLUSIONS

A structured discharge plan that is tailored to the individual patient probably brings about a small reduction in the initial hospital length of stay and readmissions to hospital for older people with a medical condition, may slightly increase patient satisfaction with healthcare received. The impact on patient health status and healthcare resource use or cost to the health service is uncertain.

Is comprehensive geriatric assessment hospital at home a cost-effective alternative to hospital admission for older people?

BACKGROUND

hospital level healthcare in the home guided by comprehensive geriatric assessment (CGA) might provide a less costly alternative to hospitalisation for older people.

OBJECTIVE

to determine the cost-effectiveness of CGA admission avoidance hospital at home (HAH) compared with hospital admission.

DESIGN/INTERVENTION

a cost-effectiveness study alongside a randomised trial of CGA in an admission avoidance HAH setting, compared with admission to hospital.

PARTICIPANTS/SETTING

older people considered for a hospital admission in nine locations across the UK were randomised using a 2:1 randomisation schedule to admission avoidance HAH with CGA (N = 700), or admission to hospital with CGA when available (N = 355).

MEASUREMENTS

quality adjusted life years, resource use and costs at baseline and 6 months; incremental cost-effectiveness ratios were calculated. The main analysis used complete cases.

RESULTS

adjusting for baseline covariates, HAH was less costly than admission to hospital from a health and social care perspective (mean -£2,265, 95% CI: -4,279 to -252), and remained less costly with the addition of informal care costs (mean difference -£2,840, 95% CI: -5,495 to -185). There was no difference in quality adjusted survival. Using multiple imputation for missing data, the mean difference in health and social care costs widened to -£2,458 (95% CI: -4,977 to 61) and societal costs remained significantly lower (-£3,083, 95% CI: -5,880 to -287). There was little change to quality adjusted survival.

CONCLUSIONS

CGA HAH is a cost-effective alternative to admission to hospital for selected older people.

Transitional Care Management from Emergency Services to Communities: An Action Research Study

In recent years, nurses have developed projects in the area of hospital to community transition. The objective of the present study was to analyze the transitional care offered to elderly people after they used emergency services and were discharged to return to the community. The action research method was chosen. The participants were nurses, elderly people 70 years old or older, and their caregivers. The study was carried out from October 2018 to August 2019. The data were collected by means of semi-structured interviews with the nurses, analysis of medical records, participatory observation, phone calls to the elderly people and caregivers, and team meetings. The qualitative data were submitted to Bardin’s content analysis. Statistical treatment was carried out by applying SPSS version 23.0. The institution’s research ethics committee approved the research. Only 31.4% of the sample experienced care continuity after discharge, and the rate of readmission to emergency services during the first 30 days after discharge was 33.4%. The referral letters lacked data on information provided to patients or caregivers, and nurses mentioned difficulties in communication between care levels, as well as obstacles to teamwork; they also mentioned that the lack of health policies and clinical rules to formalize transitional care between the hospital and the community perpetuated non-coordination of care between the two contexts. The low level of literacy of patients and their relatives are mentioned as a cause for not understanding the information regarding seeking primary health care services and handing the discharge letter. It was concluded that there is an urgent need to mobilize health teams toward action in the patients’ process of returning home, and this factor must be taken into account in care planning.

Preferences and priorities to manage clinical uncertainty for older people with frailty and multimorbidity: a discrete choice experiment and stakeholder consultations

BACKGROUND

Clinical uncertainty is inherent for people with frailty and multimorbidity. Depleted physiological reserves increase vulnerability to a decline in health and adverse outcomes from a stressor event. Evidence-based tools can improve care processes and outcomes, but little is known about priorities to deliver care for older people with frailty and multimorbidity. This study aimed to explore the preferences and priorities for patients, family carers and healthcare practitioners to enhance care processes of comprehensive assessment, communication and continuity of care in managing clinical uncertainty using evidence-based tools.

METHODS

A parallel mixed method observational study in four inpatient intermediate care units (community hospitals) for patients in transition between hospital and home. We used a discrete choice experiment (DCE) to examine patient and family preferences and priorities on the attributes of enhanced services; and stakeholder consultations with practitioners to discuss and generate recommendations on using tools to augment care processes. Data analysis used logit modelling in the DCE, and framework analysis for consultation data.

RESULTS

Thirty-three patients participated in the DCE (mean age 84 years, SD 7.76). Patients preferred a service where family were contacted on admission and discharge (β 0.36, 95% CI 0.10 to 0.61), care received closer to home (β - 0.04, 95% CI - 0.06 to - 0.02) and the GP is fully informed about care (β 0.29, 95% CI 0.05-0.52). Four stakeholder consultations (n = 48 participants) generated 20 recommendations centred around three main themes: tailoring care processes to manage multiple care needs for an ageing population with frailty and multimorbidity; the importance of ongoing communication with patient and family; and clear and concise evidence-based tools to enhance communication between clinical teams and continuity of care on discharge.

CONCLUSION

Family engagement is vital to manage clinical uncertainty. Both patients and practitioners prioritise engaging the family to support person-centred care and continuity of care within and across care settings. Patients wished to maximise family involvement by enabling their support with a preference for care close to home. Evidence-based tools used across disciplines and services can provide a shared succinct language to facilitate communication and continuity of care at points of transition in care settings.

Improved outcomes with delayed admission to post-acute care: results of a natural experiment

PURPOSE

To determine the effectiveness of a post-acute care scheme by exploiting a natural experiment.

METHODS

We used a reduction in funding for an Irish PAC scheme based in private nursing homes as a natural experiment to explore the effectiveness of this scheme in a single large general hospital.

RESULTS

Compared with an equivalent 3-month period in 2017 (pre-change, N = 169), those admitted to PAC in 2019 (post-change, N = 179), spent a median 6 days longer in acute care, although total duration spent in healthcare settings was the same. Compared with 2017, readmissions to hospital within 90 days of discharge (43/179 (24.0% v 58/169 (34.3%), p = 0.03) and discharge to long-term care from the PAC facility (3 (1.7%) v 14 (8.3%), p = 0.004) were significantly lower in 2019.

CONCLUSION

Our results suggest that the longer stay in acute care and shorter stay in PAC was beneficial for patients and led to improved outcomes.

Multidimensional Prognostic Index and Mortality in Intermediate Care Facilities: A Retrospective Study

Multidimensional prognostic index (MPI) is a frailty assessment tool used for stratifying prognosis in older hospitalized people, but data regarding older people admitted to intermediate care facilities (ICFs) are missing. The aim of this study is to evaluate whether MPI can predict mortality in older patients admitted to the ICFs. MPI was calculated using different domains explored by a standard comprehensive geriatric assessment and categorized into tertiles (MPI-1 ≤ 0.20, MPI-2 0.20-0.34, MPI-3 > 0.34). A Cox's regression analysis, taking mortality as the outcome, was used, reporting the results as hazard ratios (HRs) with 95% confidence intervals (CIs). In total, 653 older patients were enrolled (mean age: 82 years, 59.1% females). Patients in MPI-2 (HR = 3.66; 95%CI: 2.45-5.47) and MPI-3 (HR = 6.22; 95%CI: 4.22-9.16) experienced a higher risk of mortality, compared to MPI-1. The accuracy of MPI in predicting mortality was good (area under the curve (AUC) = 0.74, 95%CI: 0.70-0.78). In conclusion, our study showed that prognostic stratification, as assessed by the MPI, was associated with a significantly different risk of mortality in older patients admitted to the ICFs, indicating the necessity of using a CGA-based tool for better managing older people in this setting as well.

Staff views of a hospital at home model implemented in a Scottish care setting

Purpose

Demographic and financial challenges mean prioritising a shift in healthcare provision from acute to community settings. One well-evidenced model encapsulating this is 'hospital at home', however limited research has examined staffs' views on its implementation, which may inform service development and increase job satisfaction. The aim within was to explore the staff perspective of implementing a 'hospital at home' model in a Scottish care setting which can inform service provision and ultimately increase job satisfaction.

Methods

The 'Acute Care @ Home' (AC@H) service had a multi-disciplinary team. Referrals were predominantly received from a geriatric hospital ward. Inclusion criteria were older adults with geriatric syndromes and who required care input for a duration between one to seven days. In-depth staff interviews (N = 13) were conducted and analysed thematically to understand barriers and facilitators to implementation. These were supplemented with questionnaires assessing constructs of interest including training, communication and overall satisfaction.

Results

Several themes urged from our study: inter-team and intra-team collaboration, service development and operation, and scaling considerations. High job satisfaction was reported (mean score 73%), particularly due to a perceived non-hierarchical team structure and inclusive management style. Staff attributed positive outcomes through better identifying patients' needs at home compared to in hospital. Continuity of care facilitated rapport building. Recruitment challenges restricted the acuity and volume of patients the team were able to care for.

Conclusions

This qualitative methodology could be useful for future implementation of intermediate care resources for the future health and care system building. Patient assessments at home, as opposed to in hospital, in conjunction with care continuity by staff, may mitigate against hospital risks and better facilitate reablement. Where recruitment challenges are present, agile models of care delivery should be considered.

Big Data-Enabled Analysis of Factors Affecting Patient Waiting Time in the Nephrology Department of a Large Tertiary Hospital

The length of waiting time has become an important indicator of the efficiency of medical services and the quality of medical care. Lengthy waiting times for patients will inevitably affect their mood and reduce satisfaction. For patients who are in urgent need of hospitalization, delayed admission often leads to exacerbation of the patient's condition and may threaten the patient's life. We gathered patients' information about outpatient visits and hospital admissions in the Nephrology Department of a large tertiary hospital in western China from January 1st, 2014, to December 31st, 2016, and we used big data-enabled analysis methods, including univariate analysis and multivariate linear regression models, to explore the factors affecting waiting time. We found that gender (P=0.048), the day of issuing the admission card (Saturday, P=0.028), the applied period for admission (P < 0.001), and the registration interval (P < 0.001) were positive influencing factors of patients' waiting time. Disease type (after kidney transplantation, P < 0.001), number of diagnoses (P=0.037), and the day of issuing the admission card (Sunday, P=0.001) were negative factors. A linear regression model built using these data performed well in the identification of factors affecting the waiting time of patients in the Nephrology Department. These results can be extended to other departments and could be valuable for improving patient satisfaction and hospital service quality by identifying the factors affecting waiting time.

Predictors of adverse outcomes using a multidimensional nursing assessment in an Italian community hospital

BACKGROUND

There is growing evidence about the role of nurses in patient outcomes in several healthcare settings. However, there is still a lack of evidence about the transitional care setting. We aimed to assess the association between patient characteristics identified in a multidimensional nursing assessment and outcomes of mortality and acute hospitalization during community hospital stay.

METHODS

A retrospective observational study was performed on patients consecutively admitted to a community hospital (CH) in Loreto (Ancona, Italy) between January 1st, 2018 and May 31st, 2019. The nursing assessment included sociodemographic characteristics, functional status, risk of falls (Conley Score) and pressure damage (Norton scale), nursing diagnoses, presence of pressure sores, feeding tubes, urinary catheters or vascular access devices and comorbidities. Two logistic regression models were developed to assess the association between patient characteristics identified in a multidimensional nursing assessment and outcomes of mortality and acute hospitalization during CH stay.

RESULTS

We analyzed data from 298 patients. The mean age was 83 ± 9.9 years; 60.4% (n = 180) were female. The overall mean length of stay was 42.8 ± 36 days (32 ± 32 days for patients who died and 33.9 ± 35 days for patients who had an acute hospitalization, respectively). An acute hospitalization was reported for 13.4% (n = 40) of patients and 21.8% (n = 65) died. An increased risk of death was related to female sex (OR 2.25, 95% CI 1.10-4.62), higher Conley Score (OR 1.19; 95% CI 1.03-1.37) and having a vascular access device (OR 3.64, 95% CI 1.82-7.27). A higher Norton score was associated with a decreased risk of death (OR 0.71, 95% CI 0.62-0.81). The risk for acute hospitalization was correlated with younger age (OR 0.94, 95% CI 0.91-0.97), having a vascular access device (OR 2.33, 95% CI 1.02-5.36), impaired walking (OR 2.50, 95% CI 1.03-6.06) and it is inversely correlated with a higher Conley score (OR 0.84, 95% CI 0.77-0.98).

CONCLUSION

Using a multidimensional nursing assessment enables identification of risk of nearness of end of life and acute hospitalization to target care and treatment. The present study adds further knowledge on this topic and confirms the importance of nursing assessment to evaluate the risk of patients' adverse outcome development.

Understanding transitional care programs for older adults who experience delayed discharge: a scoping review

Background

Many hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. However, little is known about the contextual factors (i.e., patient, staff and environmental characteristics) that may influence the implementation and outcomes of TCPs. This scoping review aims to answer: 1) What are socio-demographic and/or clinical characteristics of older patients served by TCPs?; 2) What are the core components provided by TCPs?; and 3) What patient, caregiver, and health system outcomes have been investigated and what changes in these outcomes have been reported for TCPs?

Methods

The six-step scoping review framework and PRISMA-ScR checklist were followed. Studies were included if they presented models of TCPs and evaluated them in community-dwelling older adults (65+) experiencing or at-risk for delayed discharge. The data synthesis was informed by a framework, consistent with Donabedian’s structure-process-outcome model.

Results

TCP patients were typically older women with multiple chronic conditions and some cognitive impairment, functionally dependent and living alone. The review identified five core components of TCPs: assessment; care planning and monitoring; treatment; discharge planning; and patient, family and staff education. The main outcomes examined were functional status and discharge destination. The results were discussed with a view to inform policy makers, clinicians and administrators designing and evaluating TCPs as a strategy for addressing delayed hospital discharges.

Conclusion

TCPs can influence outcomes for older adults, including returning home. TCPs should be designed to incorporate interdisciplinary care teams, proactively admit those at risk of delayed discharge, accommodate persons with cognitive impairment and involve care partners. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02099-9.

Utilizing the care coordination Atlas as a framework: An integrative review of transitional care models

Introduction

Care coordination reduces care fragmentation and costs while improving health care quality. Transitional care programs, guided by tested models are an important component of effective care coordination, and have been found to reduce adverse events and prevent hospital readmissions. Using the Care Coordination Atlas as a framework, this article reports an integrative review of two transitional care models including analysis of model components, implementation factors, and associated 30-day all-cause hospital readmission rates.

Methods

Integrative review methodology. PubMed and Scopus databases were searched from January 2015 to July 2020. Fourteen studies set in 18 skilled nursing facilities and 50 hospitals were selected for data extraction and analysis.

Results

The ReEngineered Discharge model had five components and the Better Outcomes by Optimizing Safe Transitions model had eight components in the nine Care Coordination Atlas domains. Communication dominated activities in both models while neither addressed accountability/responsibility. Implementation was influenced by leadership commitment to understanding complexity of the models, culture change, integration of models into workflows, and associated labor costs. Model implementation studies consistently reported improvements in facilities’ 30-day all-cause hospital readmission rates.

Discussion

The Care Coordination Atlas was a useful framework to guide analysis of transitional care models. Leadership commitment to and participation in model implementation is vital. The models do not focus beyond the immediate post-discharge period limiting the impact on chronic disease management. Frameworks such as the Care Coordination Atlas are useful to help guide development of care coordination activities and associations with readmission rates.

Characteristics and mortality rates among patients requiring intermediate care: a national cohort study using linked databases

BACKGROUND

Adults increasingly live and die with chronic progressive conditions into advanced age. Many live with multimorbidity and an uncertain illness trajectory with points of marked decline, loss of function and increased risk of end of life. Intermediate care units support mainly older adults in transition between hospital and home to regain function and anticipate and plan for end of life. This study examined the patient characteristics and the factors associated with mortality over 1 year post-admission to an intermediate care unit to inform priorities for care.

METHODS

A national cohort study of adults admitted to intermediate care units in England using linked individual-level Hospital Episode Statistics and death registration data. The main outcome was mortality within 1 year from admission. The cohort was examined as two groups with significant differences in mortality between main diagnosis of a non-cancer condition and cancer. Data analysis used Kaplan-Meier curves to explore mortality differences between the groups and a time-dependant Cox proportional hazards model to determine mortality risk factors.

RESULTS

The cohort comprised 76,704 adults with median age 81 years (IQR 70-88) admitted to 220 intermediate care units over 1 year in 2016. Overall, 28.0% died within 1 year post-admission. Mortality varied by the main diagnosis of cancer (total n = 3680, 70.8% died) and non-cancer condition (total n = 73,024, 25.8% died). Illness-related factors had the highest adjusted hazard ratios [aHRs]. At 0-28 days post-admission, risks were highest for non-cancer respiratory conditions (pneumonia (aHR 6.17 [95%CI 4.90-7.76]), chronic obstructive pulmonary disease (aHR 5.01 [95% CI 3.78-6.62]), dementia (aHR 5.07 [95% CI 3.80-6.77]) and liver disease (aHR 9.75 [95% CI 6.50-14.6]) compared with musculoskeletal disorders. In cancer, lung cancer showed largest risk (aHR 1.20 [95%CI 1.04-1.39]) compared with cancer 'other'. Risks increased with high multimorbidity for non-cancer (aHR 2.57 [95% CI 2.36-2.79]) and cancer (aHR 2.59 [95% CI 2.13-3.15]) (reference: lowest).

CONCLUSIONS

One in four patients died within 1 year. Indicators for palliative care assessment are respiratory conditions, dementia, liver disease, cancer and rising multimorbidity. The traditional emphasis on rehabilitation and recovery in intermediate care units has changed with an ageing population and the need for greater integration of palliative care.

The Importance of Taking a Patient-Centered, Community-Based Approach to Preventing and Managing Frailty: A Public Health Perspective

Across the world, life expectancy is increasing. However, the years of life gained do not always correspond to healthy life years, potentially leading to an increase in frailty. Given the extent of population aging, the association between frailty and age and the impact of frailty on adverse outcomes for older people, frailty is increasingly being recognized to be a significant public health concern. Early identification of the condition is important to help older adults regain function and to prevent the negative outcomes associated with the syndrome. Despite the importance of diagnosing frailty, there is no definitive evidence or consensus of whether screening should be routinely implemented. A broad range of screening and assessment instruments have been developed taking a biopsychosocial approach, characterizing frailty as a dynamic state resulting from deficits in any of the physical, psychological and social domains, which contribute to health. All these aspects of frailty should be identified and addressed using an integrated and holistic approach to care. To achieve this goal, public health and primary health care (PHC) need to become the fulcrum through which care is offered, not only to older people and those that are frail, but to all individuals, favoring a life-course and patient-centered approach centered around integrated, community-based care. Public health personnel should be trained to address frailty not merely from a clinical perspective, but also in a societal context. Interventions should be delivered in the individuals' environment and within their social networks. Furthermore, public health professionals should contribute to education and training on frailty at a community level, fostering community-based interventions to support older adults and their caregivers to prevent and manage frailty. The purpose of this paper is to offer an overview of the concept of frailty for a public health audience in order to raise awareness of the multidimensional aspects of frailty and on how these should be addressed using an integrated and holistic approach to care.