"It's a waiting game" a qualitative study of the experience of carers of patients who require an alternate level of care

Transitional care programs for older adults moving from hospital to home in Canada: A systematic review of text and opinion

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.

Factors Associated with Alternate Level of Care Status Designation: a Case-Control Study and Model to Optimize Care Trajectories

Background

As health-care demand is growing, our health-care system will require the optimization of the care trajectories. Patients with an alternate level of care (ALC) status could be a target for flow optimization. We aimed to characterize ALC patients and risk factors for ALC status, and to propose an integrated model to analyze the trajectory of ALC patients and discuss solutions to reduce their burden.

Methods

A case-control design was used to compare 60 ALC and 60 non-ALC patients admitted to the geriatric unit of the Centre hospitalier de l'Université de Montréal in 2021, collecting medical and sociodemographic data. Based on our model, univariate statistical analyses were computed to compare groups and identify risk factors for ALC status.

Results

ALC patients were less independent (22% performed five to six activities of daily living vs. 43%, p = .03). Both groups were comparable in terms of mobility and neurocognitive disorders. ALC patients were more likely to receive a new diagnosis of a neurocognitive disorder or new behavioural or psychological symptoms (37% vs. 15%, p = .008). Up to 25% of ALC patients were admitted despite presenting no active medical condition (vs. 3% of non-ALC patients, p = .002).

Conclusions

The optimization of the care trajectory of ALC patients is mainly based on pre-hospital and post-hospital factors. A proportion of ALC admissions might be avoidable with additional investment in home care resources and relocation procedures. Fluidity of ALC trajectory may benefit from improved orientation at discharge procedures. Full optimization of ALC trajectories requires a systemic understanding of the health-care system.

NegotiAge: Development and pilot testing of an artificial intelligence-based family caregiver negotiation program

BACKGROUND

Family caregivers of people with Alzheimer's disease experience conflicts as they navigate health care but lack training to resolve these disputes. We sought to develop and pilot test an artificial-intelligence negotiation training program, NegotiAge, for family caregivers.

METHODS

We convened negotiation experts, a geriatrician, a social worker, and community-based family caregivers. Content matter experts created short videos to teach negotiation skills. Caregivers generated dialogue surrounding conflicts. Computer scientists utilized the dialogue with the Interactive Arbitration Guide Online (IAGO) platform to develop avatar-based agents (e.g., sibling, older adult, physician) for caregivers to practice negotiating. Pilot testing was conducted with family caregivers to assess usability (USE) and satisfaction (open-ended questions with thematic analysis).

RESULTS

Development: With NegotiAge, caregivers progress through didactic material, then receive scenarios to negotiate (e.g., physician recommends gastric tube, sibling disagrees with home support, older adult refusing support). Caregivers negotiate in real-time with avatars who are designed to act like humans, including emotional tactics and irrational behaviors. Caregivers send/receive offers, using tactics until either mutual agreement or time expires. Immediate feedback is generated for the user to improve skills training. Pilot testing: Family caregivers (n = 12) completed the program and survey. USE questionnaire (Likert scale 1-7) subset scores revealed: (1) Useful-Mean 5.69 (SD 0.76); (2) Ease-Mean 5.24 (SD 0.96); (3) Learn-Mean 5.69 (SD 0.74); (4) Satisfy-Mean 5.62 (SD 1.10). Items that received over 80% agreements were: It helps me be more effective; It helps me be more productive; It is useful; It gives me more control over the activities in my life; It makes the things I want to accomplish easier to get done. Participants were highly satisfied and found NegotiAge fun to use (91.7%), with 100% who would recommend it to a friend.

CONCLUSION

NegotiAge is an Artificial-Intelligent Caregiver Negotiation Program, that is usable and feasible for family caregivers to become familiar with negotiating conflicts commonly seen in health care.

'Safety is about partnership': Safety through the lens of patients and caregivers

INTRODUCTION

Creating safer care is a high priority across healthcare systems. Despite this, most systems tend to focus on mitigating past harm, not creating proactive solutions. Managers and staff identify safety threats often with little input from patients and their caregivers during their health encounters.

METHODS

This is a qualitative descriptive study utilizing focus groups and one-to-one interviews with patients and caregivers who were currently using (or had previously used) services in health systems across Canada. Data were analysed via inductive thematic analysis to understand existing and desired strategies to promote safer and better quality care from the perspectives of patients and caregivers.

FINDINGS

In our analysis, we identified three key themes (safety strategies) from patients' and caregivers' perspectives and experiences: Using Tools and Approaches for Engaging Patients and Caregivers in their Care; Having Accountability Processes and Mechanisms for Safe Care; and Enabling Patients and Caregivers Access to Information.

CONCLUSIONS

Safety is more than the absence of harm. Our findings outline a number of suggestions from patients and caregivers on how to make care safer, ranging from being valued on teams, participating as members of quality improvement tables, having access to health information, having access to an advocate to help make sense of information and having processes in place for disclosure and closure. Future work can further refine, implement and evaluate these strategies in practice.

PATIENT OR PUBLIC CONTRIBUTIONS

An advisory group guided the research and was co-chaired by a patient partner. Members of the advisory group spanned patient and caregiver organizations and health sectors across Canada and included three patient partners and leaders who work closely with patients and caregivers in their day-to-day work. In the research itself, we engaged 28 patients and caregivers from across Canada to learn about their safety experiences and learn what safer care looks like from their perspectives.

Transitional care programs in Canada for older adults transitioning from hospital to home: protocol for a systematic review of text and opinion

OBJECTIVE

The objective of this systematic review is to identify what transitional care programs exist across Canada, including the characteristics and outcomes of these programs.

INTRODUCTION

There is growing evidence of the benefits of transitional care programs to support older adults moving from hospital to home. However, there is limited literature identifying the types of transitional care programs that exist internationally and little evidence available within Canada.

INCLUSION CRITERIA

Sources of gray literature published from 2016 that focus on older adults receiving services from transitional care programs to move from hospital to home in Canada will be considered for inclusion. Sources of gray literature will be excluded if interventions are targeted at adults younger than 65 years, Indigenous adults younger than 55 years, or if the primary discharge destination is not an independent community dwelling. Interventions designed for older adults waiting in hospital for long-term care placement will also be excluded from this review.

METHODS

An initial limited search of Canadian national gray literature resources will be undertaken, followed by an advanced Google search of Canadian resources and news media reports. Lastly, an advanced search of Google for all 10 provinces and 3 territories will be undertaken to target examples of local transitional care programs that may not be found through a national search, such as local pilot projects, health region-specific programs, and provincial organizations. All identified sources will be retrieved and full text review of selected citations assessed in detail by 2 independent reviewers. Data about the characteristics and outcomes of transitional care programs and results will be extracted and synthesized, with a meta-aggregation approach for grading according to JBI ConQual method.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022298821.

The cost-effectiveness of a nursing home-based transitional care unit for increasing the potential for independent living in the community among hospitalized older adults

OBJECTIVE

In Canada, a persistent barrier to achieving healthcare system efficiency has been patient days accumulated by individuals with an alternate level of care (ALC) designation. Transitional care units (TCUs) may address the capacity pressures associated with ALC. We sought to assess the cost-effectiveness of a nursing home (NH) based TCU leveraging existing infrastructure to support a hospitalized older adult's transition to independent living at home.

METHODS

This case-control study included frail, older adults who received care within a function-focused TCU following a hospitalization between 1 March 2018 and 30 June 2019. TCU patients were propensity score matched to hospitalized ALC patients ("usual care"). The primary outcome was days without requiring institutional care six months following discharge, defined as institutional-free days. This was calculated by excluding all days in hospitals, rehabilitation facilities, complex continuing care facilities and NHs. Using the total direct cost of care up to discharge from TCU or hospital, the incremental cost-effectiveness ratio was calculated.

RESULTS

TCU patients spent, on average, 162.0 days institution-free (95% CI: 156.3-167.6d) within six months days post-discharge, while usual care patients spent 140.6 days institution-free (95% CI: 132.3-148.8d). TCU recipients had a lower total cost of care, by CAN$1,106 (95% CI: $-6,129-$10,319), due to the reduced hospital length of stay (mean [SD] 15.6d [13.3d] for TCU patients and 28.6d [67.4d] days for usual care). TCU was deemed the more cost-effective model of care.

LIMITATIONS

The main limitation was the potential inclusion of patients not eligible for SAFE in our usual group. To minimize this selection bias, we expanded the geographical pool of ALC patients to patients with SAFE admission potential in other area hospitals.

CONCLUSIONS

Through rehabilitative and restorative care, TCUs can reduce hospital length of stay, increase potential for independent living, and reduce risk for subsequent institutionalization.

Healthcare-Associated Adverse Events in Alternate Level of Care Patients Awaiting Long-Term Care in Hospital

INTRODUCTION

A growing number of Canadian older adults are designated alternate level of care (ALC) and await placement into long-term care (LTC) while admitted to hospital. This creates infrastructural challenges by using resources allocated for acute care during disproportionately long hospital stays. For ALC patients, hospital environments maladapted to their needs impart risk of healthcare-associated adverse events.

METHODS

In this retrospective descriptive study, we examined healthcare-associated adverse events in 156 ALC patients, 65 years old and older, awaiting long-term care while admitted to two hospitals in London, Ontario in 2015-2018. We recorded incidence of infections and antimicrobial days prescribed. We recorded incidence of non-infectious adverse events including delirium, falls, venothrombotic events, and pressure ulcers. We used a restricted cubic spline model to characterize adverse events as a function of length of stay.

RESULTS

Patients waited an average of 56 ALC days (ranging from 6 to 333 days) before LTC placement, with seven deaths occurring prior to placement. We recorded 362 total adverse events accrued over 8668 ALC days: 94 infections and 268 non-infectious adverse events. The most common hospital-acquired infections were urinary-tract infections and respiratory infections. The most common non-infectious adverse events were delirium and falls. A total of 620 antimicrobial days were prescribed for infections.

CONCLUSIONS

ALC patients incur a meaningful and predictable number of adverse events during their stay in acute care. The incidence of these adverse events should be used to educate stakeholders on risks of ALC stay and to advocate for strategies to minimize ALC days.

Variation in revascularisation use and outcomes of patients in hospital with acute myocardial infarction across six high income countries: cross sectional cohort study

OBJECTIVES

To compare treatment and outcomes for patients admitted to hospital with a primary diagnosis of ST elevation or non-ST elevation myocardial infarction (STEMI or NSTEMI) in six high income countries with very different healthcare delivery systems.

DESIGN

Retrospective cross sectional cohort study.

SETTING

Patient level administrative data from the United States, Canada (Ontario and Manitoba), England, the Netherlands, Israel, and Taiwan.

PARTICIPANTS

Adults aged 66 years and older admitted to hospital with STEMI or NSTEMI between 1 January 2011 and 31 December 2017.

OUTCOMES MEASURES

The three categories of outcomes were coronary revascularisation (percutaneous coronary intervention or coronary artery bypass graft surgery), mortality, and efficiency (hospital length of stay and 30 day readmission). Rates were standardised to the age and sex distribution of the US acute myocardial infarction population in 2017. Outcomes were assessed separately for STEMI and NSTEMI. Performance was evaluated longitudinally (over time) and cross sectionally (between countries).

RESULTS

The total number of hospital admissions ranged from 19 043 in Israel to 1 064 099 in the US. Large differences were found between countries for all outcomes. For example, the proportion of patients admitted to hospital with STEMI who received percutaneous coronary intervention in hospital during 2017 ranged from 36.9% (England) to 78.6% (Canada; 71.8% in the US); use of percutaneous coronary intervention for STEMI increased in all countries between 2011 and 2017, with particularly large rises in Israel (48.4-65.9%) and Taiwan (49.4-70.2%). The proportion of patients with NSTEMI who underwent coronary artery bypass graft surgery within 90 days of admission during 2017 was lowest in the Netherlands (3.5%) and highest in the US (11.7%). Death within one year of admission for STEMI in 2017 ranged from 18.9% (Netherlands) to 27.8% (US) and 32.3% (Taiwan). Mean hospital length of stay in 2017 for STEMI was lowest in the Netherlands and the US (5.0 and 5.1 days) and highest in Taiwan (8.5 days); 30 day readmission for STEMI was lowest in Taiwan (11.7%) and the US (12.2%) and highest in England (23.1%).

CONCLUSIONS

In an analysis of myocardial infarction in six high income countries, all countries had areas of high performance, but no country excelled in all three domains. Our findings suggest that countries could learn from each other by using international comparisons of patient level nationally representative data.

Multi-Disciplinary Discharge Coordination Team to Overcome Discharge Barriers and Address the Risk of Delayed Discharges

Background

Methods

Results

Conclusion

Putting the Patient First: A Scoping Review of Patient Desires in Canada

Patient-centred care is a key priority for governments, providers and stakeholders, yet little is known about the care preferences of patient groups. We completed a scoping review that yielded 193 articles for analysis. Five health states were used to account for the diversity of possible preferences based on health needs. Five broad themes were identified and expressed differently across the health states, including personalized care, navigation, choice, holistic care and care continuity. Patients' perspectives must be considered to meet the diverse needs of targeted patient groups, which can inform health system planning, quality improvement initiatives and targeting of investments.

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.

Do premorbid characteristics of home care clients predict delayed discharges in acute care hospitals: a retrospective cohort study in Ontario and British Columbia, Canada

BACKGROUND

Improved identification of patients with complex needs early during hospitalisation may help target individuals at risk of delayed discharge with interventions to prevent iatrogenic complications, reduce length of stay and increase the likelihood of a successful discharge home.

METHODS

In this retrospective cohort study, we linked home care assessment records based on the Resident Assessment Instrument for Home Care (RAI-HC) of 210 931 hospitalised patients with their Discharge Abstract Database records. We then undertook multivariable logistic regression analyses to identify preadmission predictive factors for delayed discharge from hospital.

RESULTS

Characteristics that predicted delayed discharge included advanced age (OR: 2.72, 95% CI 2.55 to 2.90), social vulnerability (OR: 1.27, 95% CI 1.08 to 1.49), Parkinsonism (OR: 1.34, 95% CI 1.28 to 1.41) Alzheimer's disease and related dementias (OR: 1.27, 95% CI 1.23 to 1.31), need for long-term care facility services (OR: 2.08, 95% CI 1.96 to 2.21), difficulty in performing activities of daily living and instrumental activities of daily living, falls (OR: 1.16, 95% CI 1.12 to 1.19) and problematic behaviours such as wandering (OR: 1.29, 95% CI 1.22 to 1.38).

CONCLUSION

Predicting delayed discharge prior to or on admission is possible. Characteristics associated with delayed discharge and inability to return home are easily identified using existing interRAI home care assessments, which can then facilitate the targeting of pre-emptive interventions immediately on hospital admission.

Reallocating Cancer Surgery Payments for Alternate Level of Care in Ontario: What Are the Options?

This article examines how alternate-level-of-care (ALC) days are funded through the cancer surgery funding model in Ontario and evaluates policy options to better address ALC days. The contribution of ALC days to hospital funding and the impact of removing or reallocating this funding from cancer surgery is measured. Though costs associated with ALC days in cancer surgery are low, this article highlights the need for policy options that would realign funding across the healthcare system in Ontario to better meet the needs of patients waiting for ALC, reduce pressure on inpatient bed capacity and improve value for money.

An alternate level of care plan: Co-designing components of an intervention with patients, caregivers and providers to address delayed hospital discharge challenges

Objective

To engage with patients, caregivers and care providers to co‐design components of an intervention that aims to improve delayed hospital discharge experiences.

Design

This is a qualitative study, which entailed working groups and co‐design sessions utilizing World Café and deliberative dialogue techniques to continually refine the intervention.

Setting and Participants

Our team engaged with 61 participants (patients, caregivers and care providers) in urban and rural communities across Ontario, Canada. A 7‐member Patient and Caregiver Advisory Council participated in all stages of the research.

Results

Key challenges experienced during a delayed discharge by patients, caregivers and care providers were poor communication and a lack of care services. Participants recommended a communication guide to support on‐going conversation between care providers, patients and caregivers. The guide included key topics to cover and questions to ask during initial and on‐going conversations to manage expectations and better understand the priorities and goals of patients and caregivers. Service recommendations included getting out of bed and dressed each day, addressing the psycho‐social needs of patients through tailored activities and having a storyboard at the bedside to facilitate on‐going engagement.

Discussion and Conclusions

Our findings outline ways to meaningfully engage patients and caregivers during a delayed hospital discharge. Combining this with a minimal basket of services can potentially facilitate a better care experience and outcomes for patients, their care providers and families.

Conflicts Experienced by Caregivers of Older Adults With the Health-Care System

Background:

Family caregivers of older adults frequently navigate the health system for their loved ones. As older adults experience more medical issues, the interactions between caregivers and the health system can be fraught with conflicts.

Objective:

To characterize the conflicts that caregivers of older adults experience with the health-care system.

Methods:

A cross-sectional national online survey with open-ended questions was conducted among family caregivers ascertaining experiences with the health-care system. Qualitative thematic analysis was completed using constant comparative analysis and review by a third author.

Results:

Over a 2-month period, 97 caregivers completed the survey. Common themes where caregivers experienced conflicts were Difficulty With Accessing/Communicating With Providers, Delivery of Emergency Care, Disjointed Transitional Care, Unaddressed Clinical Concerns, and Financial. Caregivers reported needing to act as patient advocates in the conflicts with the health-care system.

Conclusion:

Understanding the conflicts that family caregivers encounter with the health system provides potential targets for future interventions to combat the challenges faced by caregivers of older adults and ultimately improve delivery of geriatric care.

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

INTRODUCTION

Many hospitalised older adults experience delayed discharges due to increased postacute health and social support needs. Transitional care programmes (TCPs) provide short-term care to these patients to prepare them for transfer to nursing homes or back to the community with supports. There are knowledge gaps related to the development, implementation and evaluation of TCPs. The aims of this scoping review (ScR) are to identify the characteristics of older patients served by TCPs; criteria for transfer, components and services provided by TCPs; and outcomes used to evaluate TCPs.

METHODS AND ANALYSIS

The study involves six-step ScR and is informed by a collaborative/participatory approach whereby stakeholders engage in the development of the research questions, identification of literature, data abstraction and synthesis; and participation in consultation workshop. The search for scientific literature will be done in the Medline, PsychINFO, Emcare and CINAHL databases; as well, policies and reports that examined models of transitional care and the outcomes used to evaluate them will be reviewed. Records will be selected if they involve community dwelling older adults aged 65 years or older, or indigenous persons 45 years or older; and presented in English, French, Dutch and German languages. Records will be screened, reviewed and abstracted by two independent reviewers. Extracted data will be analysed using descriptive statistics and a narrative analysis, and organised according to Donabedian's model of structure (characteristics of older adults experiencing delayed discharge and served by TCPs), process (TCP components and services) and outcome.

ETHICS AND DISSEMINATION

This ScR does not require ethics approval. Dissemination activities include integrated knowledge translation (KT) (consultation with stakeholders throughout the study) and end-of-grant KT strategies (presentations at national and international conferences; and publication in peer-reviewed interdisciplinary journal).

Risk factors, costs and complications of delayed hospital discharge from internal medicine wards at a Canadian academic medical centre: retrospective cohort study

Background

Hospitalized patients are designated alternate level of care (ALC) when they no longer require hospitalization but discharge is delayed while they await alternate disposition or living arrangements. We assessed hospital costs and complications for general internal medicine (GIM) inpatients who had delayed discharge. In addition, we developed a clinical prediction rule to identify patients at risk for delayed discharge.

Methods

We conducted a retrospective cohort study of consecutive GIM patients admitted between 1 January 2015 and 1 January 2016 at a large tertiary care hospital in Canada. We compared hospital costs and complications between ALC and non-ALC patients. We derived a clinical prediction rule for ALC designation using a logistic regression model and validated its diagnostic properties.

Results

Of 4311 GIM admissions, 255 (6%) patients were designated ALC. Compared to non-ALC patients, ALC patients had longer median length of stay (30.85 vs. 3.95 days p < 0.0001), higher median hospital costs ($22,459 vs. $5003 p < 0.0001) and more complications in hospital (25.5% vs. 5.3% p < 0.0001) especially nosocomial infections (14.1% vs. 1.9% p < 0.0001). Sensitivity analyses using propensity score and pair matching yielded similar results. In a derivation cohort, seven significant risk factors for ALC were identified including age > =80 years, female sex, dementia, diabetes with complications as well as referrals to physiotherapy, occupational therapy and speech language pathology. A clinical prediction rule that assigned each of these predictors 1 point had likelihood ratios for ALC designation of 0.07, 0.25, 0.66, 1.48, 6.07, 17.13 and 21.85 for patients with 0, 1, 2, 3, 4, 5, and 6 points respectively in the validation cohort.

Conclusions

Delayed discharge is associated with higher hospital costs and complication rates especially nosocomial infections. A clinical prediction rule can identify patients at risk for delayed discharge.

Stakeholder perspectives of care for people living with dementia moving from hospital to care facilities in the community: a systematic review

Background

People living with dementia in care homes are regularly admitted to hospital. The transition between hospitals and care homes is an area of documented poor care leading to adverse outcomes including costly re-hospitalisation. This review aims to understand the experiences and outcomes of care for people living with dementia who undergo this transition from the perspectives of key stakeholders; people living with dementia, their families and health care professionals.

Methods

A systematic search was conducted on the CINAHL, ASSIA, EMBASE, MEDLINE, PsychINFO, and Scopus databases without any date restrictions. We hand searched reference lists of included papers. Papers were included if they focused on people living with dementia moving from hospital to a short or long term care setting in the community including sub-acute, rehabilitation, skilled nursing facilities or care homes. Titles, abstracts and full texts were screened. Two authors independently evaluated study quality using a checklist. Themes were identified and discussed to reach consensus.

Results

In total, nine papers reporting eight studies met the inclusion criteria for the systematic review. A total of 257 stakeholders participated; 37 people living with dementia, 95 family members, and 125 health and social care professionals. Studies took place in Australia, Canada, United Kingdom (UK), and the United States of America (US). Four themes were identified as factors influencing the experience and outcomes of the transition from the perspectives of stakeholders; preparing for transition; quality of communication; the quality of care; family engagement and roles.

Conclusion

This systematic review presents a compelling case for the need for robust evidence to guide best practice in this important area of multi-disciplinary clinical practice. The evidence suggests this transition is challenging for all stakeholders and that people with dementia have specific needs which need attention during this period.

Trial registration

PROSPERO Registration Number: CRD42017082041.

Patient and caregiver experience with delayed discharge from a hospital setting: A scoping review

BACKGROUND

Delayed hospital discharge occurs when patients are medically cleared but remain hospitalized because a suitable care setting is not available. Delayed discharge typically results in reduced levels of treatment, placing patients at risk of functional decline, falls and hospital-related adverse events. Caregivers often take on an active role in hospital to mitigate these risks.

OBJECTIVE

This scoping review aimed to summarize the literature on patient and caregiver experiences with delayed hospital discharge.

SEARCH STRATEGY

Seven electronic databases and grey literature were searched using keywords including alternate level of care, delayed discharge, patients, caregivers and experiences.

INCLUSION CRITERIA

Included articles met the following criteria: (a) patient or caregiver population 18 years or older; (b) delayed discharge from a hospital setting; (c) included experiences with delayed discharge; (d) peer-reviewed or grey literature; and (e) published between 1 January 1998 and 16 July 2018.

DATA EXTRACTION

Data were extracted from the seven included articles using Microsoft Excel 2016 to facilitate a thorough analysis and comparison.

MAIN RESULTS

Study themes were grouped into five elements of the delayed discharge experience: (1) overall uncertainty; (2) impact of hospital staff and physical environment; (3) mental and physical deterioration; (4) lack of engagement in decision making and need for advocacy; and (5) initial disbelief sometimes followed by reluctant acceptance.

CONCLUSION

This review provides a foundation to guide future research, policies and practices to improve patient and caregiver experiences with delayed hospital discharge, including enhanced communication with patients and families and programmes to reduce deconditioning.