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Barber BV, Gregg EE, Drake EK, Macdonald M, Hickey M, Flynn C, Moody E, Gallant SM, McConnell E, Weeks LE. Transitional care programs for older adults moving from hospital to home in Canada: A systematic review of text and opinion. PLoS One 2024; 19:e0307306. [PMID: 39024298 PMCID: PMC11257371 DOI: 10.1371/journal.pone.0307306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 07/02/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Investing in transitional care programs is critical for ensuring continuity of health and coordinated care for older adults transitioning across health settings. However, literature delineating the scope of transitional care programs across Canada is limited. The aim of this systematic review of text and opinion is to characterize Canadian transitional care programs for older adults transitioning from hospital to home. METHODS Following JBI guidelines for systematic review of text and opinion, we conducted a search of Canadian grey literature sources published online between 2016 to 2023. A 3-phase search was undertaken for: 1) Canadian databases and organizational websites; 2) advanced Google search of national sources and news media reports; and 3) advanced Google search of provincial/territorial sources. Two reviewers independently screened sources for eligibility against inclusion criteria. Data were extracted by one reviewer and verified by a second. Textual data were extracted from multiple sources to characterize each transitional care program. RESULTS Grey literature search produced a total of 17,092 text and opinion sources, identifying 119 transitional care programs in Canada. Model of care was a key characteristic defining the design and delivery of transitional care programs within community (n = 42), hospital (n = 45), and facility-based (n = 32) settings. Programs were characterized by goal, population and eligibility, setting and length of program, intervention and services, and healthcare team members. Patient, caregiver, and health system outcomes were reported for 18 programs. The province of Ontario has the most transitional care programs (n = 84) and reported outcomes, followed by British Columbia (n = 10). CONCLUSIONS Characterizing transitional care programs is important for informing health services planning and scaling up of transitional care program models across Canada. Recognizing transitional care programs as a core health service is critical to meet the health care needs of older adults at the right time and place. TRIAL REGISTRATION PROSPERO ID 298821.
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Affiliation(s)
- Brittany V. Barber
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
- Aligning Health Needs and Evidence for Transformative Change: A JBI Centre of Excellence, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Emily E. Gregg
- Department of Nursing & Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
- University of New Brunswick (UNB) Saint John Collaboration for Evidence-Informed Healthcare: A JBI Centre of Excellence, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Emily K. Drake
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
- Aligning Health Needs and Evidence for Transformative Change: A JBI Centre of Excellence, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Marilyn Macdonald
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
- Aligning Health Needs and Evidence for Transformative Change: A JBI Centre of Excellence, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Madison Hickey
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
- Aligning Health Needs and Evidence for Transformative Change: A JBI Centre of Excellence, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Chloe Flynn
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
- Aligning Health Needs and Evidence for Transformative Change: A JBI Centre of Excellence, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Elaine Moody
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
- Aligning Health Needs and Evidence for Transformative Change: A JBI Centre of Excellence, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sarah M. Gallant
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
- Aligning Health Needs and Evidence for Transformative Change: A JBI Centre of Excellence, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Erin McConnell
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
- Aligning Health Needs and Evidence for Transformative Change: A JBI Centre of Excellence, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lori E. Weeks
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
- Aligning Health Needs and Evidence for Transformative Change: A JBI Centre of Excellence, Dalhousie University, Halifax, Nova Scotia, Canada
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Liu S, Xiong XY, Chen H, Liu MD, Wang Y, Yang Y, Zhang MJ, Xiang Q. Transitional Care in Patients with Heart Failure: A Concept Analysis Using Rogers' Evolutionary Approach. Risk Manag Healthc Policy 2023; 16:2063-2076. [PMID: 37822727 PMCID: PMC10563773 DOI: 10.2147/rmhp.s427495] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023] Open
Abstract
Objective The purpose of this study was to clarify the concept of transitional care in patients with heart failure. Background Transitional care is increasingly being applied in patients with heart failure, but the concept of transitional care in heart failure patients is not uniform and confused with other definitions, which limits further research and practice on transitional care for these patients. Design Rodgers' evolutionary concept analysis. Methods A comprehensive literature search was conducted using the PUBMED, EMBASE, EBSCO, Chinese Biological Medicine (CBM), CNKI, and WANFANG databases (up to January 26, 2023). We used Rodgers' evolutionary concept analysis method to identify related concepts, attributes, antecedents, and consequences of transitional care in patients with heart failure. Results A total of 33 articles were included. The following attributes belonging to transitional care in patients with heart failure were extracted from the literature: self-care, multidisciplinary collaboration, and information transmission. The antecedents were patients' health status, the health literacy of patients and caregivers, the role functions of the main implementer and social and medical resources. Consequences were separated into two categories: patient-centered health outcomes (all-cause mortality, health-related quality of life, discharge preparedness, self-care behaviors, satisfaction of patients) and healthcare utilization outcomes (hospital readmission, length of hospital stay, emergency department visits). Conclusion This study found that transitional care in heart failure patients is a systemic care process during a vulnerable period that improves patient self-management and coordination between hospital resources and social support systems for continuous management to promote smooth patient transitions between different locations. This concept analysis will inform healthcare providers in designing evidence-based interventions and quality improvement strategies to ensure that transition processes lead to desired outcomes. In addition, this study will also be helpful for developing specific assessment tools to identify patients with HF who need transitional care.
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Affiliation(s)
- Si Liu
- School of Nursing, Nan Chang University, Nan Chang, Jiang Xi, People’s Republic of China
- Nursing Department, the Second Affiliated Hospital of Nan Chang University, Nan Chang, Jiang Xi, People’s Republic of China
| | - Xiao-yun Xiong
- Nursing Department, the Second Affiliated Hospital of Nan Chang University, Nan Chang, Jiang Xi, People’s Republic of China
| | - Hua Chen
- School of Nursing, Nan Chang University, Nan Chang, Jiang Xi, People’s Republic of China
| | - Meng-die Liu
- School of Nursing, Nan Chang University, Nan Chang, Jiang Xi, People’s Republic of China
| | - Ying Wang
- School of Nursing, Nan Chang University, Nan Chang, Jiang Xi, People’s Republic of China
| | - Ying Yang
- School of Nursing, Nan Chang University, Nan Chang, Jiang Xi, People’s Republic of China
| | - Mei-jun Zhang
- School of Nursing, Nan Chang University, Nan Chang, Jiang Xi, People’s Republic of China
| | - Qin Xiang
- School of Nursing, Nan Chang University, Nan Chang, Jiang Xi, People’s Republic of China
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Park Y, Kim J, Kim S, Moon D, Jo H. Effects of Transitional Care after Hospital Discharge in Patients with Chronic Obstructive Pulmonary Disease: An Updated Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6053. [PMID: 37297657 PMCID: PMC10253211 DOI: 10.3390/ijerph20116053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023]
Abstract
This study aimed to systematically review the effects of transitional care programs on healthcare use and quality of life in patients with chronic obstructive pulmonary disease (COPD). Several databases were searched for randomized controlled trials conducted over the past five years, and their quality was evaluated using the Cochrane Risk of Bias 2.0 tool. For indicators with available statistical information, a meta-analysis was performed using RevMan 5.4, and a narrative review was performed for the rest of the results. In the meta-analysis, no statistically significant difference was observed between the intervention and control groups in the number of readmissions and emergency room visits due to COPD. The relative risk (RR) of readmission for COPD was lower in the intervention group. Respiratory-related quality of life tended to be better in the intervention group, though not significantly. Physical capacity was improved in the intervention group. Considering the characteristics of the complex intervention, the context and factors of cases where the expected results could be obtained and cases where the expected results could not be obtained were reviewed and discussed. Based on the results of the analysis, implications for the development of better protocols were presented.
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Affiliation(s)
- Yukyung Park
- Department of Preventive Medicine, Kangwon National University Hospital, Chuncheon 24289, Republic of Korea
| | - Jiwon Kim
- Department of Elderly Clinical Counseling, Seoul Graduate School of Counseling Psychology, Seoul 03136, Republic of Korea
| | - Sukyoung Kim
- Department of Health Policy and Management, Kangwon National University School of Medicine, Chuncheon 24341, Republic of Korea
| | - Dahae Moon
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon 24289, Republic of Korea
| | - Heuisug Jo
- Department of Health Policy and Management, Kangwon National University School of Medicine, Chuncheon 24341, Republic of Korea
- Division of Public Health, Kangwon National University Hospital, Chuncheon 24289, Republic of Korea
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Naylor MD, Hirschman KB, Morgan B, McHugh M, Hanlon AL, Ahrens M, McCauley K, Shaid EC, Pauly MV. The study protocol to evaluate implementation of the transitional care model in four U.S. healthcare systems during the Covid-19 pandemic. Arch Gerontol Geriatr 2023; 108:104944. [PMID: 36709563 PMCID: PMC9873366 DOI: 10.1016/j.archger.2023.104944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/10/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023]
Abstract
This study protocol describes the conceptual framework, design, and methods being employed to evaluate the implementation of the Transitional Care Model (TCM) as part of a randomized controlled trial. The trial, designed to examine the health and cost outcomes of at-risk hospitalized older adults, is being conducted in the context of the COVID-19 pandemic. This parallel study is guided by the Practical, Robust, Implementation and Sustainability Model (PRISM) and uses a fixed, mixed methods convergent parallel design to identify challenges encountered by participating hospitals and post-acute and community-based providers that impact the implementation of the TCM with fidelity, strategies implemented to address those challenges and the relationships between challenges, strategies, and rates of fidelity to TCM's core components over time. Prior to the study's launch and throughout its implementation, qualitative and quantitative data related to COVID and non-COVID challenges are being collected via surveys and meetings with healthcare system staff. Strategies implemented to address challenges and fidelity to TCM's core components are also being assessed. Analyses of quantitative (established metrics to evaluate TCM's core components) and qualitative data (barriers and facilitators to implementation) are being conducted independently. These datasets are then merged and interpreted together. General linear and mixed effects modeling using all merged data and patients' socio-demographic and social determinants of health characteristics, will be used to examine relationships between key variables and fidelity rates. Implications of study findings in the context of COVID-19 and future research opportunities are suggested. Trial registration: ClinicalTrials.gov Identifier: NCT04212962.
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Affiliation(s)
- Mary D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104.
| | - Karen B Hirschman
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Brianna Morgan
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Molly McHugh
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Alexandra L Hanlon
- Center for Biostatistics and Health Data Science, College of Science, Department of Statistics, Virginia Tech, Four Riverside Circle, Roanoke, VA 24016
| | - Monica Ahrens
- Center for Biostatistics and Health Data Science, College of Science, Department of Statistics, Virginia Tech, Four Riverside Circle, Roanoke, VA 24016
| | - Kathleen McCauley
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Elizabeth C Shaid
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Mark V Pauly
- Wharton School, University of Pennsylvania, Philadelphia, PA 19104
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Ferretti-Rebustini REDL, Souza-Talarico JND, Fhon JRS, Greenberg SA. El papel de la evaluación en la enfermería de práctica avanzada gerontológica basada en competencias. Rev Esc Enferm USP 2022. [DOI: 10.1590/1980-220x-reeusp-2022-0072es] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
RESUMEN El envejecimiento de la población es un desafío a los sistemas de salud y requiere que los profesionales de enfermería en gerontología de práctica avanzada (EGPA) aborden los requisitos específicos y complejos del cuidado de los adultos mayores. La EGPA pone en ejecución prácticas basadas en evidencia dirigidas a pacientes y familiares para la promoción y protección de la salud, prevención de enfermedades, así como su recuperación y rehabilitación. En la gerontología de práctica avanzada basada en competencias, la evaluación integral es esencial para la puesta en práctica de un plan de cuidados. En este ensayo teórico reflexionamos sobre el papel de la evaluación en la enfermería en gerontología de práctica avanzada basada en competencias. Desde nuestro punto de vista, la valoración gerontológica hacia una práctica excelente debe ser integral, multidimensional, interdisciplinar y planificada. La EGPA debe abarcar competencias efectivas en habilidades clínicas y prácticas del cuidado; alfabetización en salud; cuidado colaborativo; gestión de sistemas para la continuidad del cuidado; ética, defensa y agencia moral; y la práctica a través de la investigación basada en la evidencia. Los modelos gerontológicos de cuidado y las competencias de la EGPA sirven como marco de su práctica, mientras que la evaluación es fundamental para un cuidado accesible a los adultos mayores.
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Ferretti-Rebustini REDL, Souza-Talarico JND, Fhon JRS, Greenberg SA. The role of assessment in competence-based gerontological advanced practice nursing. Rev Esc Enferm USP 2022; 56:e20220072. [DOI: 10.1590/1980-220x-reeusp-2022-0072en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/27/2022] [Indexed: 11/07/2022] Open
Abstract
ABSTRACT Population aging challenges healthcare systems, requiring gerontological advanced practice nurses (GAPN) to address specific and complex care requirements of older adults. GAPN implement evidence-based practices directed to patients and families, focusing on health promotion and protection, disease prevention, recovery, and rehabilitation. In competence-based gerontological advanced practice, comprehensive geriatric assessment is essential for implementing the care plan. In this theoretical essay we reflect about the role of assessment in competence-based advanced nursing practice directed to the care of older adults. From our perspective, geriatric assessment for a high-quality practice must be comprehensive, multidimensional, interdisciplinary, and planned. GAPN must have solid competencies for clinical skills and caring practices; education for health literacy; collaborative care; system management for continuity of care; ethics, advocacy, and moral agency; and evidenced-based practice inquiry. Gerontological models of care and GAPN competencies serve as frameworks to guide practice while assessment is fundamental for providing age-friendly care to older adults.
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