So many options, where do we start? An overview of the care transitions literature

Devan Kansagara, Joseph Chiovaro, David Kagen, Stephen Jencks, Kerry Rhyne, Maya O'Neil, Karli Kondo, Rose Relevo, Makalapua Motu'apuaka, Michele Freeman, Honora Englander

Research output: Contribution to journalArticle

26 Citations (Scopus)

Abstract

BACKGROUND: Health systems are faced with a large array of transitional care interventions and patient populations to whom such activities might apply. PURPOSE: To summarize the health and utilization effects of transitional care interventions, and to identify common themes about intervention types, patient populations, or settings that modify these effects. DATA SOURCES: PubMed and Cochrane Database of Systematic Reviews (January 1950-May 2014), reference lists, and technical advisors. STUDY SELECTION: Systematic reviews of transitional care interventions that reported hospital readmission as an outcome. DATA EXTRACTION: We extracted transitional care procedures, patient populations, settings, readmissions, and health outcomes. We identified commonalities and compiled a narrative synthesis of emerging themes. DATA SYNTHESIS: Among 10 reviews of mixed patient populations, there was consistent evidence that enhanced discharge planning and hospital-at-home interventions reduced readmissions. Among 7 reviews in specific patient populations, transitional care interventions reduced readmission in patients with congestive heart failure and general medical populations. In general, interventions that reduced readmission addressed multiple aspects of the care transition, extended beyond hospital stay, and had the flexibility to accommodate individual patient needs. There was insufficient evidence on how caregiver involvement, transition to sites other than home, staffing, patient selection practices, or care settings modified intervention effects. CONCLUSIONS: Successful interventions are comprehensive, extend beyond hospital stay, and have the flexibility to respond to individual patient needs. The strength of evidence should be considered low because of heterogeneity in the interventions studied, patient populations, clinical settings, and implementation strategies.

Original languageEnglish (US)
Pages (from-to)221-230
Number of pages10
JournalJournal of Hospital Medicine
Volume11
Issue number3
DOIs
StatePublished - Mar 1 2016

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Patient Transfer
Population
Patient Readmission
Length of Stay
Health
Patient Discharge
PubMed
Patient Selection
Caregivers
Patient Care
Heart Failure
Transitional Care
Databases

ASJC Scopus subject areas

  • Health Policy
  • Assessment and Diagnosis
  • Care Planning
  • Fundamentals and skills
  • Leadership and Management

Cite this

So many options, where do we start? An overview of the care transitions literature. / Kansagara, Devan; Chiovaro, Joseph; Kagen, David; Jencks, Stephen; Rhyne, Kerry; O'Neil, Maya; Kondo, Karli; Relevo, Rose; Motu'apuaka, Makalapua; Freeman, Michele; Englander, Honora.

In: Journal of Hospital Medicine, Vol. 11, No. 3, 01.03.2016, p. 221-230.

Research output: Contribution to journalArticle

Kansagara, D, Chiovaro, J, Kagen, D, Jencks, S, Rhyne, K, O'Neil, M, Kondo, K, Relevo, R, Motu'apuaka, M, Freeman, M & Englander, H 2016, 'So many options, where do we start? An overview of the care transitions literature', Journal of Hospital Medicine, vol. 11, no. 3, pp. 221-230. https://doi.org/10.1002/jhm.2502
Kansagara, Devan ; Chiovaro, Joseph ; Kagen, David ; Jencks, Stephen ; Rhyne, Kerry ; O'Neil, Maya ; Kondo, Karli ; Relevo, Rose ; Motu'apuaka, Makalapua ; Freeman, Michele ; Englander, Honora. / So many options, where do we start? An overview of the care transitions literature. In: Journal of Hospital Medicine. 2016 ; Vol. 11, No. 3. pp. 221-230.
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