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Volumn 12, Issue JULY-SEPTEMBER 20, 2012, Pages

Transitional care programs: Who is left behind? a systematic review

Author keywords

Care transitions; Comorbidity; Rehospitalization; Self care; Systematic review

Indexed keywords


EID: 84883025350     PISSN: None     EISSN: 15684156     Source Type: Journal    
DOI: 10.5334/ijic.805     Document Type: Article
Times cited : (32)

References (56)
  • 4
    • 33846308154 scopus 로고    scopus 로고
    • Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure
    • McCauley KM, Bixby MB, Naylor MD. Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Disease Management 2006;9(5):302-310.
    • (2006) Disease Management , vol.9 , Issue.5 , pp. 302-310
    • McCauley, K.M.1    Bixby, M.B.2    Naylor, M.D.3
  • 7
    • 2442514163 scopus 로고    scopus 로고
    • Sooner and healthier: A randomised controlled trial and interview study of an early discharge rehabilitation service for older people
    • Cunliffe AL, Gladman JR, Husbands SL, Miller P, Dewey ME, Harwood RH. Sooner and healthier: a randomised controlled trial and interview study of an early discharge rehabilitation service for older people. Age and Ageing 2004;33:246-252.
    • (2004) Age and Ageing , vol.33 , pp. 246-252
    • Cunliffe, A.L.1    Gladman, J.R.2    Husbands, S.L.3    Miller, P.4    Dewey, M.E.5    Harwood, R.H.6
  • 8
    • 0037392164 scopus 로고    scopus 로고
    • Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs
    • Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society 2003;51(4):549-555.
    • (2003) Journal of the American Geriatrics Society , vol.51 , Issue.4 , pp. 549-555
    • Coleman, E.A.1
  • 9
    • 0039769315 scopus 로고
    • Managing the tranition from hospital to home
    • Bull MJ. Managing the tranition from hospital to home. Qualitative Health Research 1992;2(1):27-41.
    • (1992) Qualitative Health Research , vol.2 , Issue.1 , pp. 27-41
    • Bull, M.J.1
  • 10
    • 0037418131 scopus 로고    scopus 로고
    • The incidence and severity of adverse events affecting patients after discharge from the hospital
    • Forster AJ, Murf HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine 2003;138(3):161-167.
    • (2003) Annals of Internal Medicine , vol.138 , Issue.3 , pp. 161-167
    • Forster, A.J.1    Murf, H.J.2    Peterson, J.F.3    Gandhi, T.K.4    Bates, D.W.5
  • 11
    • 0036518069 scopus 로고    scopus 로고
    • Transitions through postacute and long-term care settings: Patterns of use and outcomes for a national cohort of elders
    • Murtaugh CM, Litke A. Transitions through postacute and long-term care settings: patterns of use and outcomes for a national cohort of elders. Medical Care 2002;40(3):227-236.
    • (2002) Medical Care , vol.40 , Issue.3 , pp. 227-236
    • Murtaugh, C.M.1    Litke, A.2
  • 12
    • 0027389893 scopus 로고
    • Hazards of hospitalization of elderly
    • Creditor MC. Hazards of hospitalization of elderly. Annals of Internal Medicine 1993;118:219-223.
    • (1993) Annals of Internal Medicine , vol.118 , pp. 219-223
    • Creditor, M.C.1
  • 13
    • 0029972604 scopus 로고    scopus 로고
    • Hospital admission risk profile (HARP): Identifying older patients at risk for functional decline following acute medical illness and hospitalization
    • Sager MA, Rudberg MA, Jalaluddin M, Franke T, Inouye SK, Landefeld CS, et al. Hospital admission risk profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization. Journal of the American Geriatrics Society 1996;44(3):251-257.
    • (1996) Journal of the American Geriatrics Society , vol.44 , Issue.3 , pp. 251-257
    • Sager, M.A.1    Rudberg, M.A.2    Jalaluddin, M.3    Franke, T.4    Inouye, S.K.5    Landefeld, C.S.6
  • 15
    • 79953692392 scopus 로고    scopus 로고
    • Integrated care for the frail elderly
    • Heckman G. Integrated care for the frail elderly. Healthcare Papers 2011;11:62-68.
    • (2011) Healthcare Papers , vol.11 , pp. 62-68
    • Heckman, G.1
  • 16
    • 4043117712 scopus 로고    scopus 로고
    • Multicenter randomized trial of a comprehensive hospital discharge and outpatient heart failure management program
    • Atienza F, Anguita M, Martinez-Alzamora N, Osca J, Ojeda S, Almenar L, et al. Multicenter randomized trial of a comprehensive hospital discharge and outpatient heart failure management program. European Journal of Heart Failure 2004;6(5):643-652.
    • (2004) European Journal of Heart Failure , vol.6 , Issue.5 , pp. 643-652
    • Atienza, F.1    Anguita, M.2    Martinez-Alzamora, N.3    Osca, J.4    Ojeda, S.5    Almenar, L.6
  • 17
    • 0036547415 scopus 로고    scopus 로고
    • Quality of life of individuals with heart failure: A randomized trial of the effectiveness of two models of hospital-to-home transition
    • Harrison MB, Browne GB, Roberts J, Tugwell P, Gafini A, Graham ID. Quality of life of individuals with heart failure: a randomized trial of the effectiveness of two models of hospital-to-home transition. Medical Care 2002;40(4):271-282.
    • (2002) Medical Care , vol.40 , Issue.4 , pp. 271-282
    • Harrison, M.B.1    Browne, G.B.2    Roberts, J.3    Tugwell, P.4    Gafini, A.5    Graham, I.D.6
  • 18
    • 27644548055 scopus 로고    scopus 로고
    • A randomized clinical trial of the effectiveness of a discharge planning intervention in hospitalized elders with hip fracture due to falling
    • Huang T, Liang S. A randomized clinical trial of the effectiveness of a discharge planning intervention in hospitalized elders with hip fracture due to falling. Journal of Clinical Nursing 2005;14(10):1193-1201.
    • (2005) Journal of Clinical Nursing , vol.14 , Issue.10 , pp. 1193-1201
    • Huang, T.1    Liang, S.2
  • 19
    • 13844272247 scopus 로고    scopus 로고
    • Effects of a nurse-led, clinic and home-based intervention on recurrent hospital use in chronic heart failure
    • Thompson DR, Roebuck A, Stewart S. Effects of a nurse-led, clinic and home-based intervention on recurrent hospital use in chronic heart failure. European Journal of Heart Failure 2005;7(3):377-384.
    • (2005) European Journal of Heart Failure , vol.7 , Issue.3 , pp. 377-384
    • Thompson, D.R.1    Roebuck, A.2    Stewart, S.3
  • 20
    • 0034168398 scopus 로고    scopus 로고
    • A decade of transitional care research with vulnerable elders
    • Naylor M. A decade of transitional care research with vulnerable elders. Journal of Cardiovascular Nursing 2000;14(3):1-14.
    • (2000) Journal of Cardiovascular Nursing , vol.14 , Issue.3 , pp. 1-14
    • Naylor, M.1
  • 21
    • 84857416423 scopus 로고    scopus 로고
    • Evidence-based risk factors for adverse health outcomes in older patients after discharge home and assessment tools: A systematic review
    • Preyde M, Brassard K. Evidence-based risk factors for adverse health outcomes in older patients after discharge home and assessment tools: a systematic review. Journal of Evidence-based Social Work 2011;8(5):445-68.
    • (2011) Journal of Evidence-based Social Work , vol.8 , Issue.5 , pp. 445-468
    • Preyde, M.1    Brassard, K.2
  • 22
    • 84883021959 scopus 로고    scopus 로고
    • Canadian Institute of Health Information. Analysis in Brief, Alternative Level of Care in Canada [Internet]. Canada; 2011 [Updated January 14, 2009; cited August 11, Available from:
    • Canadian Institute of Health Information. Analysis in Brief, Alternative Level of Care in Canada [Internet]. Canada; 2011 [Updated January 14, 2009; cited August 11, 2011]. Available from: https://secure.cihi.ca/free_products/ALC_AIB_FINAL.pdf.
    • (2011)
  • 23
    • 0037395674 scopus 로고    scopus 로고
    • Improving the quality of transitional care for persons with complex care needs
    • Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society 2003;51(4):556-557.
    • (2003) Journal of the American Geriatrics Society , vol.51 , Issue.4 , pp. 556-557
    • Coleman, E.A.1    Boult, C.2
  • 24
    • 1642329318 scopus 로고    scopus 로고
    • Untangling the concepts of disability, frailty, and comorbidity: Implications for improved targeting and care
    • Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. Journals of Gerontology: Series A 2004;59(3):255-263.
    • (2004) Journals of Gerontology: Series A , vol.59 , Issue.3 , pp. 255-263
    • Fried, L.P.1    Ferrucci, L.2    Darer, J.3    Williamson, J.D.4    Anderson, G.5
  • 26
    • 18644378022 scopus 로고    scopus 로고
    • The impact of change in cognitive functioning and cognitive decline on disability, well-being and the use of healthcare services in older persons. Results of longitudinal aging study Amsterdam
    • Comijis HC, Dik MG, Aartsen MJ, Deeg DJ, Jonker C. The impact of change in cognitive functioning and cognitive decline on disability, well-being and the use of healthcare services in older persons. Results of longitudinal aging study Amsterdam. Dementia and Geriatric Cognitive Disorders 2005;19(5-6):316-23.
    • (2005) Dementia and Geriatric Cognitive Disorders , vol.19 , Issue.5-6 , pp. 316-323
    • Comijis, H.C.1    Dik, M.G.2    Aartsen, M.J.3    Deeg, D.J.4    Jonker, C.5
  • 27
    • 84883020766 scopus 로고    scopus 로고
    • Dysthymia and depression increase risk of dementia and mortality among older veterans
    • Epub 2011 May 18
    • Byers AL, Covinsky KE, Barnes DE, Yaffe K. Dysthymia and depression increase risk of dementia and mortality among older veterans. The American Journal of Geriatric Psychiatry 2011. http://www.ncbi.nlm.nih.gov/pubmed/21597358. Epub 2011 May 18.
    • (2011) The American Journal of Geriatric Psychiatry
    • Byers, A.L.1    Covinsky, K.E.2    Barnes, D.E.3    Yaffe, K.4
  • 29
    • 85034457495 scopus 로고    scopus 로고
    • Frequently asked questions. [Internet]. Canada, updated September 1, 2008; cited August 14, 2011
    • Seniors Canada: working for seniors. Frequently asked questions. [Internet]. Canada; 2008 [updated September 1, 2008; cited August 14, 2011]. Available from: http://www.seniors.gc.ca/content.jsp?lang=en&font=0&contentid=1#one
    • (2008) Seniors Canada: Working For Seniors
  • 30
    • 79952584191 scopus 로고    scopus 로고
    • The effect of guided care teams on the use of health services: Results from a cluster-randomized controlled trial
    • Boult C, Reider L, Leff B, Frick KD, Boyd CM, Wolf JL, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Archives of Internal Medicine 2011;171(5):460-466.
    • (2011) Archives of Internal Medicine , vol.171 , Issue.5 , pp. 460-466
    • Boult, C.1    Reider, L.2    Leff, B.3    Frick, K.D.4    Boyd, C.M.5    Wolf, J.L.6
  • 31
    • 0038067879 scopus 로고    scopus 로고
    • Identification of factors predictive of hospital readmissions for patients with heart failure
    • Schwarz KA, Elman CS. Identification of factors predictive of hospital readmissions for patients with heart failure. Heart and Lung 2003;32(2):88-99.
    • (2003) Heart and Lung , vol.32 , Issue.2 , pp. 88-99
    • Schwarz, K.A.1    Elman, C.S.2
  • 32
    • 85034458443 scopus 로고    scopus 로고
    • Pearson M. 30-day COPD readmissions relate to disease severity and demographic factors rather than simply organization and delivery of hospital care
    • Hare J, Thompson E, Bodger K, Walker P, Pearson M. 30-day COPD readmissions relate to disease severity and demographic factors rather than simply organization and delivery of hospital care. Thorax 2011;66:A107-A108.
    • (2011) Thorax , vol.66
    • Hare, J.1    Thompson, E.2    Bodger, K.3    Walker, P.4
  • 34
    • 68749115220 scopus 로고    scopus 로고
    • Effects of a postdischarge transitional care programme for patients with coronary heart disease in China: A randomized controlled trial
    • Zhao Y, Wong FK. Effects of a postdischarge transitional care programme for patients with coronary heart disease in China: a randomized controlled trial. Journal of Clinical Nursing 2009;18(17):2444-2455.
    • (2009) Journal of Clinical Nursing , vol.18 , Issue.17 , pp. 2444-2455
    • Zhao, Y.1    Wong, F.K.2
  • 35
    • 67649482684 scopus 로고    scopus 로고
    • Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle
    • Koehler BE, Richter KM, Youngblood L, Cohen BA, Prengler ID, Cheng D, et al. Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. Journal of Hospital Medicine 2009;4:211-218.
    • (2009) Journal of Hospital Medicine , vol.4 , pp. 211-218
    • Koehler, B.E.1    Richter, K.M.2    Youngblood, L.3    Cohen, B.A.4    Prengler, I.D.5    Cheng, D.6
  • 36
    • 0036023208 scopus 로고    scopus 로고
    • Heart failure management: Multidisciplinary care has intrinsic benefit above the optimization of medical care
    • McDonald K, Ledwidge M, Cahill J, Quigley P, Maurer B, Travers B, et al. Heart failure management: multidisciplinary care has intrinsic benefit above the optimization of medical care. Journal of Cardiac Failure 2002;8(3):142-148.
    • (2002) Journal of Cardiac Failure , vol.8 , Issue.3 , pp. 142-148
    • McDonald, K.1    Ledwidge, M.2    Cahill, J.3    Quigley, P.4    Maurer, B.5    Travers, B.6
  • 37
    • 0032933180 scopus 로고    scopus 로고
    • Effects of education and support on self-care and resource utilization in patients with heart failure
    • Jaarsma T, Halfens R, Huijer Abu-Saad H, Dracup K, Gorgels T, Van RJ, et al. Effects of education and support on self-care and resource utilization in patients with heart failure. European Heart Journal 1999;20(9):674-682.
    • (1999) European Heart Journal , vol.20 , Issue.9 , pp. 674-682
    • Jaarsma, T.1    Halfens, R.2    Hujer Abu-Saad, H.3    Dracup, K.4    Gorgels, T.5    Van, R.J.6
  • 40
    • 36949028922 scopus 로고    scopus 로고
    • A randomized controlled trial of a community nurse-supported hospital discharge programme in older patients with chronic heart failure
    • Kwok T, Lee J, Woo J, Lee DT, Griffiths S. A randomized controlled trial of a community nurse-supported hospital discharge programme in older patients with chronic heart failure. Journal of Clinical Nursing 2008;17(1):109-117.
    • (2008) Journal of Clinical Nursing , vol.17 , Issue.1 , pp. 109-117
    • Kwok, T.1    Lee, J.2    Woo, J.3    Lee, D.T.4    Griffiths, S.5
  • 41
    • 77949404939 scopus 로고    scopus 로고
    • Further application of the care transitions intervention: Results of a randomized controlled trial conducted in a fee-for-service setting
    • Parry C, Min S, Chugh A, Chalmers S, Coleman E. Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Services Quarterly 2009;28(2-3):84-89.
    • (2009) Home Health Care Services Quarterly , vol.28 , Issue.2-3 , pp. 84-89
    • Parry, C.1    Min, S.2    Chugh, A.3    Chalmers, S.4    Coleman, E.5
  • 42
    • 84856758265 scopus 로고    scopus 로고
    • Stolee P Navigation roles which support chronically ill older adults through health care transitions: A systematic review of the literature
    • Manderson B, McMurray J, Piraino E, Stolee P Navigation roles which support chronically ill older adults through health care transitions: a systematic review of the literature. Health and Social Care in the Community 2011;20(2):113-127.
    • (2011) Health and Social Care In the Community , vol.20 , Issue.2 , pp. 113-127
    • Manderson, B.1    McMurray, J.2    Piraino, E.3
  • 44
    • 0036803520 scopus 로고    scopus 로고
    • Research on co-morbidity, contextual barriers, and stigma: An introduction to the special issue
    • Muehrer P, Research on co-morbidity, contextual barriers, and stigma: an introduction to the special issue. J Psychosomatic Research 2002;53(4):843-845.
    • (2002) J Psychosomatic Research , vol.53 , Issue.4 , pp. 843-845
    • Muehrer, P.1
  • 45
    • 0027981586 scopus 로고
    • The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients
    • Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. The American Journal of Medicine 1994;97(3):278-8.
    • (1994) The American Journal of Medicine , vol.97 , Issue.3 , pp. 278
    • Inouye, S.K.1
  • 47
    • 0041469874 scopus 로고    scopus 로고
    • Cognitive impairment, chronic medical illness, and risk of mortality in an elderly cohort
    • Feil D, Marmon T, Unutzer J. Cognitive impairment, chronic medical illness, and risk of mortality in an elderly cohort. The American Journal of Geriatric Psychiatry 2003;11(5):551-560.
    • (2003) The American Journal of Geriatric Psychiatry , vol.11 , Issue.5 , pp. 551-560
    • Feil, D.1    Marmon, T.2    Unutzer, J.3
  • 48
    • 85039824904 scopus 로고    scopus 로고
    • Public Health Agency of Canada, Chapter 3: the health and well-being of Canadian seniors [Webpage in the Internet]. Canada: Public Health Agency; 2010. [updated October 28, 2010; cited August 15, Available from
    • Public Health Agency of Canada. The chief public health officer's report on the state of public health in Canada 2010. Chapter 3: the health and well-being of Canadian seniors [Webpage in the Internet]. Canada: Public Health Agency; 2010. [updated October 28, 2010; cited August 15, 2011]. Available from: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2010/fr-rc/cphorsphc-respcacsp-06-eng.php.
    • (2011) The Chief Public Health Officer's Report On the State of Public Health In Canada 2010
  • 51
    • 77956732586 scopus 로고    scopus 로고
    • Transitioning the patient with acute coronary syndrome from inpatient to primary care
    • Villanueva T. Transitioning the patient with acute coronary syndrome from inpatient to primary care. Journal of Hospital Medicine 2010;5(S4):S8-S18.
    • (2010) Journal of Hospital Medicine , vol.5 S4
    • Villanueva, T.1
  • 52
    • 1642365729 scopus 로고    scopus 로고
    • Social support and patient adherence to medical treatment
    • A meta-analysis
    • Dimatteo RM. Social support and patient adherence to medical treatment. A meta-analysis. Health Psychology 2004;23(2):207-218.
    • (2004) Health Psychology , vol.23 , Issue.2 , pp. 207-218
    • Dimatteo, R.M.1
  • 53
    • 0043135046 scopus 로고    scopus 로고
    • The influence of social support on chronic illness self-management: A review and directions for research
    • Gallant MP. The influence of social support on chronic illness self-management: a review and directions for research. Health Education and Behavior 2003;30(2):170-195.
    • (2003) Health Education and Behavior , vol.30 , Issue.2 , pp. 170-195
    • Gallant, M.P.1
  • 55
    • 1842784019 scopus 로고    scopus 로고
    • Designing randomized controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: A consensus report
    • Ferrucci L, Guralnik JM, Studenski S, Fried LP, Cutler GB, Walston JD. Designing randomized controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. Journal of the American Geriatrics Society 2004;52(4):625-634.
    • (2004) Journal of the American Geriatrics Society , vol.52 , Issue.4 , pp. 625-634
    • Ferrucci, L.1    Guralnik, J.M.2    Studenski, S.3    Fried, L.P.4    Cutler, G.B.5    Walston, J.D.6
  • 56
    • 40749147609 scopus 로고    scopus 로고
    • Canadian Cardiovascular Society consensus conference on heart failure-2008 Update: Best practices for the transition of care of heart failure patients, and the recognition, investigation, and treatment of cardiomyopathies
    • Arnold JM, Howlett JG, Ducharme A, Ezekowitz JA, Gardner MJ, Giannetti N, et al. Canadian Cardiovascular Society consensus conference on heart failure-2008 Update: best practices for the transition of care of heart failure patients, and the recognition, investigation, and treatment of cardiomyopathies. Canadian Journal of Cardiology 2008;24:21-40.
    • (2008) Canadian Journal of Cardiology , vol.24 , pp. 21-40
    • Arnold, J.M.1    Howlett, J.G.2    Ducharme, A.3    Ezekowitz, J.A.4    Gardner, M.J.5    Giannetti, N.6


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