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Transitional-care programs can improve the use of healthcare services by older adults living in the community

Weeks LE, Macdonald M, Martin-Misener R, et al. The impact of transitional care programs on health services utilization in community-dwelling older adults: A systematic review JBI Database of Systematic Reviews and Implementation Reports. 2018; 16(2): 345-384.

Review question

  • What is the impact of transitional care programs on the use of hospital and other healthcare services by older adults living in the community?


  • Transitional-care programs refer to a wide range of interventions to improve the coordination and continuity of care for people being transferred between different locations or different levels of care within the same location. Transitional-care programs often aim to help patients and caregivers navigate the system, to plan their care, learn about services and answer their questions.
  • There is growing evidence that transitional-care programs could reduce unnecessary hospital admissions, readmissions and premature nursing-home placements.

How the review was done

  • A detailed search of six electronic databases was conducted to find relevant studies published up to May 2016. Studies that focused on the effect of transitional-care programs on the use of healthcare services by older adults living in the community were included in the systematic review.
  • A total of 6,315 studies were identified in searches, and 23 were included in the review after assessing their eligibility.
  • The review was funded by the School of Nursing at Dalhousie University.

What the researchers found

  • The review revealed that transitional-care programs generally began with a baseline assessment to identify patients’ and caregivers’ needs, and included support that was tailored to these needs. Common types of support included: coordinating and facilitating care across settings and providers; supporting access to health and community services; providing information and education; monitoring health; assessing the physical environment of the participant; providing support with medication; helping navigate the system; and supporting patient and caregiver empowerment, autonomy and self-management. Nurses were the most common providers delivering the transitional-care programs.
  • The review identified several key findings about transitional-care programs, including: they reduce rehospitalization rates over time; they may increase the use of primary-care services (which helps to deliver preventive care); they may reduce visits of staff providing home-care services; programs that lasted one month or less appeared to be as effective as longer interventions in reducing the use of hospital services; and they may have limited impact on the use of emergency departments and nursing homes.


  • Despite the diversity of transitional-care programs, research evidence shows that they can improve the use of healthcare services by older adults living in the community.


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

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