Does transitional care prevent older adults from rehospitalization? A review

Journal of Evidence-Informed Social Work

Volumn 12, Issue 3, 2015, Pages 261-271

  Kim, Hyejin ^a   Thyer, Bruce A ^a  

^a FLORIDA STATE UNIVERSITY   (United States)

Author keywords

Medicare costs; Randomized controlled trials; Rehospitalization; Systematic review; Transitional care

Indexed keywords

ADULT; AGED; BIBLIOGRAPHIC DATABASE; ENGLISH (LANGUAGE); EXPERIMENTAL MODEL; EXPERIMENTAL STUDY; FEMALE; FOLLOW UP; HOSPITAL READMISSION; HUMAN; HUMAN EXPERIMENT; MALE; MEDICARE; NARRATIVE; PREVALENCE; TRANSITIONAL CARE; UNITED STATES; ECONOMICS; HEALTH CARE COST; HEALTH STATUS; LENGTH OF STAY; ORGANIZATION AND MANAGEMENT; PATIENT SATISFACTION; STATISTICS AND NUMERICAL DATA; VERY ELDERLY;

AGED; AGED, 80 AND OVER; HEALTH EXPENDITURES; HEALTH STATUS; HUMANS; LENGTH OF STAY; MEDICARE; PATIENT READMISSION; PATIENT SATISFACTION; TRANSITIONAL CARE; UNITED STATES;

EID: 85016496280     PISSN: 23761407     EISSN: 23761415     Source Type: Journal    
DOI: 10.1080/15433714.2013.827140     Document Type: Review

References (27)

1. Coleman, E. A., & Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51, 556–557.
2. Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166, 1822–1828.
3. Crowley, R., Wolfe, I., Lock, K., & McKee, M. (2011). Improving the transition between paediatric and adult healthcare: A systematic review. Archives of Disease in Childhood. Advance online publication. doi:10.1136/adc.2010.202473
4. DeFrances, C. J., & Podgornik, M. N. (2006). 2004 National hospital discharge survey. Advance Data, 371, 1–19.
5. Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals Internal Medicine, 138, 161–167.
6. He, W., Sengupta, M., Velkoff, V. A., & DeBarros, K. A. (2005). 65+ in the United States: 2005. U.S. Census Bureau: Current Population Reports. Retrieved from http://www.census.gov/prod/2006pubs/p23-209.pdf
7. Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360, 1418–1428.
8. Keenan, S. P., Massel, D., Inman, K. J., & Sibbald, W. J. (1998). A systematic review of the cost-effectiveness of noncardiac transitional care units. Chest, 113, 172–177.
9. Koehler, B. E., Richter, K. M., Youngblood, L., Cohen, B. A., Prengler, I. D., Cheng, D., & Masica, A. L. (2009). 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, 4, 211–218.
10. LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby-Whitehead, J., & Hanson, L. C. (2010). Interventions to improve transitional care between nursing homes and hospitals: A systematic review. Journal of the American Geriatrics Society, 58, 777–782.
11. Masica, A. L. (2009). 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, 4, 211–218.
12. Misky, G. J., Wald, H. L., & Coleman, E. A. (2010). Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. Journal of Hospital Medicine, 5, 392–397.
13. Moore, C., Wisnivesky, J., Williams, S., & McGinn, T. (2003). Medical errors related to discontinuity of care from an inpatient to an outpatient Setting. Journal of General Internal Medicine, 18, 646–651.
14. Murtaugh, C. M., & Litke, A. (2002). Transitions through postacute and long-term care settings: Patterns of use and outcomes for a national cohort of elders. Medical Care, 40, 227–236.
15. Naylor, M. D. (2002). Transitional care of older adults. Annual Review of Nursing Research, 20, 127–147.
16. Naylor, M. D., Brooten, D. A., Jones, R., Lavizzo-Mourey, R., Mezey, M. D., & Pauly, M. V. (1994). Comprehensive discharge planning for the hospitalized elderly: A randomized controlled trial. Annals of Internal Medicine, 120, 999–1006.
17. Naylor, M. D., Brooten, D. A., Campbell, R. L., Jacobsen, B., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA, 281, 613–620.
18. Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 52, 675–684.
19. Parry, C., Min, S.-J., Chugh, A., Chalmers, S., & Coleman, E. A. (2009). 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, 28, 84–99.
20. Peikes, D., Chen, A., Schore, J., & Brown, R. (2009). Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA, 301, 603–618.
21. Phillips, C. O., Wright, S. M., Kern, D. E., Singa, R. M., Shepperd, S., & Rubin, H. R. (2004). Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: A meta-analysis. JAMA, 291, 1358–1367.
22. Popejoy, L. L., Moylan, K., & Galambos, C. (2009). A review of discharge planning research of older adults 1990–2008. Western Journal of Nursing Research, 31, 923–947.
23. Rich, M. W., Beckham, V., Wittenberg, C., Leven, C. L., Freedland, K. E., & Carney, R. M. (1995). A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. The New England Journal of Medicine, 333, 1190–1195.
24. Rich, M. W., Vinson, J. M., Sperry, J. C., Shah, A. S., Spinner, L. R., Chung, M. K., & Davila-Roman, V. (1993). Prevention of readmission in elderly patients with congestive heart failure: Results of a prospective, randomized pilot study. Journal of General Internal Medicine, 8, 585–590.
25. Snow, V., Beck, D., Budnitz, T., Miller, D. C., Potter, J., Wears, R. L., Weiss, K. B., & Williams, M. V. (2009). Transitions of care consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine. Journal of Hospital Medicine, 4, 364–370.
26. Tsilimingras, D., & Bates, D. W. (2008). Addressing postdischarge adverse events: A neglected area. The Joint Commission Journal on Quality and Patient Safety, 34, 85–97.
27. Walraven, C., Mamdani, M., Fang, J., & Austin, P. C. (2004). Continuity of care and patient outcomes after hospital discharge. Journal of General Internal Medicine, 19, 624–645.