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Improvements of patient outcomes in Transitional Care interventions to older citizens with multiple chronic conditions – An umbrella review

Author:

Connie Berthelsen

University Hospital Zealand,Denmark University of Southern Denmark, DK
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Abstract

Introduction: The population of older patients with multiple chronic conditions is increasing worldwide. The trajectories of older patients with multiple chronic conditions are often complicated by risk factors and complex care initiatives. Naylor and Hirschman developed The Transitional Care Model to support clinicians in planning and managing transitional care of older patients with multiple chronic conditions, who are transitioning from hospital to home-based care. However, knowledge is needed to identify the most effective elements to support transitions between hospital and home. 

Aims and Methods: The aim of the study was to identify, appraise, synthesize, and describe the combined evidence from systematic reviews according to the content of interventions comprising elements from the Transitional Care Model and to their improvements of patient outcomes.

An umbrella review methodology following recommendations of AMSTAR2 was used. A search for eligible reviews was conducted in PubMed/MEDLINE, CINAHL, PsycInfo, PROQUEST and EMBASE in April 2021 based on the search terms: “Patients≥ 60 years”, “multi-morbidity”, “Transitional care model”, “Transitional care”, and “Systematic review”. Studies were reviewed by title, abstract and full-text following PRISMA guidelines. Quality was appraised using the AMSTAR2. 

Results: The electronic search identified 829 systematic reviews. Initially 728 were excluded, and another 44 were excluded for not meeting the full-text inclusion criteria. This umbrella review comprises five systematic reviews constituting 62 intervention studies (RCTs=59) conducted between 1990 and 2019.

There was a large diversity of elements from the Transitional Care Model used in the intervention studies of the five reviews. However, all reviews reported the use of the element “Coordinating care” in actions of discharge assessment and care planning and “Educating and promoting self-management” through coaching and educating. Four reviews reported use of the element “Promoting continuity” and “Relying on transitional care nurses”, where nurses were prime coordinators of the trajectories.

Of the 12 patient outcomes examined, significant improvements as a result of using elements from the Transitional Care Model were: decrease in readmissions and financial costs and an increase in patients’ quality of life and satisfaction during discharge. 

Conclusions: It is difficult to say if specific intervention elements of the Transitional Care Model make the difference. Findings indicate that a combination of all elements are important, to reach significant improvements in older patients’ transitions from hospital to home, because all elements cover vital aspects of the discharge process.

Implications for applicability/transferability: A specific focus on coordination and continuity in transitional care, as well as educating patients, are important in the discharge process of older patients with multiple chronic conditions. Nurses with specialized knowledge, experience and expertise in transitional care are needed to ensure the transitional trajectories for the older patients.

How to Cite: Berthelsen C. Improvements of patient outcomes in Transitional Care interventions to older citizens with multiple chronic conditions – An umbrella review. International Journal of Integrated Care. 2022;22(S3):209. DOI: http://doi.org/10.5334/ijic.ICIC22102
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Published on 04 Nov 2022.

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