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Transition interventions for chronically-ill older adults associated with decreased mortality, readmission, and readmission days

Le Berre M, Maimon G, Sourial N, Gueriton M, Vedel I. Impact of transitional care services for chronically ill older patients: A systematic evidence review Journal of the American Geriatrics Society. 2017; 65(7): 1597-1608.

Review question

      How effective are interventions to support the transition of chronically-ill older patients from hospital to primary-care settings?


      Healthcare systems are facing a dual challenge today of managing both a rapidly aging population and an increase in chronic diseases.

      Today, more than 90% of Americans over the age of 65 have at least one chronic disease, the management of which is often complex, involving a combination of routine, emergency, and specialized care.

      Transitions from hospital to primary care for older patients with chronic diseases are complex and can lead to increased service use and mortality risk.

      Research evidence shows that most unwanted outcomes come from a lack of coordination and continuity during transitions. Problems with information exchange and collaboration at hospital discharge are often reported, with the primary-care physicians receiving either incomplete, late or no discharge summaries at all. Patients have also frequently reported problems with their discharge, notably the lack of clear information and the lack of follow-up.

      Transition interventions are being widely implemented across health systems in response to these challenges. These interventions can involve education on self-management, discharge planning, structured follow-up, and coordination among the different healthcare professionals.

      The aim of this systematic review is to examine the effectiveness of interventions targeting transitions from hospital to primary-care setting for chronically ill older patients.

How the review was done

      Review authors conducted a detailed search of four research databases for articles published between January 1, 1995, and April 9, 2015.

      Reference lists of included studies were screened manually for additional relevant articles.

      A total of 10,234 articles were retrieved from the initial search, of which 92 were included in this review.

      This research funded by the Canadian Institutes of Health Research. No conflicts of interest were declared.

What the researchers found

      On average, the transition care services analyzed in this review started 7.9 days after discharge, lasted 179.7 days, and involved 7.1 contacts through phone calls or home visits.

      Most interventions included phone contacts or home visits, and provided phone availability or a hotline service. Nurses played an important role in the majority of these interventions.

      Most interventions included educational components and medication management. Examples of educational components included motivational interviews (a counseling technique in which professionals try to elicit behavioural changes), individualized face-to-face coaching, brochures, and videotapes. Other components of the interventions involved multidisciplinary coordination, such as written reports sent to primary-care physicians or specialists, collaboration of various healthcare professionals working as a team, or specialists made available to healthcare professionals for clinical consultation and guidance.

      Overall, the review clearly identified a sustained improvement in mortality rates compared to usual care starting 6 months post-discharge.

      These positive post-discharge outcomes were likely related to the better continuity of care provided by the transition services, with communication between different healthcare professionals being emphasized as a key component of most interventions.

      Improved self-management skills could also have contributed to the positive effect, since education about chronic diseases and closer monitoring of patients through phone calls was another component of most interventions. Finally, involvement of a pharmacist was thought to be another key component of the most successful interventions.

      These key components of successful transition interventions also seemed to fit with patients’ preferences and experiences. The interpersonal continuity of care, included in most interventions by keeping the same facilitator from the beginning to the end of the intervention, was found to be especially valued by older patients, resulting in greater patients' willingness and ability to take actions to manage their own health and care, better adherence to treatment, and disease control through enhanced therapeutic relationships.

      Overall, transition interventions were not shown to impact the quality of life of older patients with chronic disease.


      Transition interventions for older patients with chronic disease discharged from hospital to home led to better outcomes in mortality, readmission, and readmission days.


Systematic review
A comprehensive evaluation of the available research evidence on a particular topic.

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