Impact of transitional care services for chronically ill older patients: a systematic evidence review
Abstract
Transitions in care from hospital to primary care for older patients with chronic diseases (CD) are complex and lead to increased mortality and service use. In response to these challenges, transitional care (TC) interventions are being widely implemented. They encompass education on self-management, discharge planning, structured follow-up and coordination among the different healthcare professionals. We conducted a systematic review to determine the effectiveness of interventions targeting transitions from hospital to the primary care setting for chronically ill older patients.. Randomized controlled trials were identified through Medline, CINHAL, PsycInfo, EMBASE (1995-2015). Two independent reviewers performed the study selection, data extraction and assessment of study quality (Cochrane "Risk of Bias"). Risk differences (RD) and number needed to treat (NNT) or mean differences (MD) were calculated using a random-effects model. From 10,234 references, 92 studies were included. Compared to usual care, significantly better outcomes were observed: a lower mortality at 3 (RD: -0.02 [-0.05, 0.00]; NNT: 50), 6, 12 and 18 months post-discharge, a lower rate of ED visits at 3 months (RD: -0.08 [-0.15, -0.01]; NNT: 13), a lower rate of readmissions at 3 (RD: -0.08 [-0.14, -0.03]; NNT: 7), 6, 12 and 18 months and a lower mean of readmission days at 3 (MD: -1.33; [-2.15, -0.52]), 6, 12 and 18 months. No significant differences were observed in quality of life. In conclusion, TC improves transitions for older patients and should be included in the reorganization of healthcare services.
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Studies demonstrate the effectiveness of transitional care at improving outcomes after transitions from hospital to home.
“Studies demonstrate the effectiveness of transitional care at improving outcomes after transitions from hospital to home;9, 10”
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- Authors
- Le Berre, M., Maimon, G., Sourial, N., Guériton, M., & Vedel, I.
- Affiliations
- Lady Davis Institute of the Jewish General Hospital Montreal Québec Canada
- Jewish General Hospital (CA)
- Corresponding author
- Vedel, Isabelle
- Venue
- Journal of the American Geriatrics Society
- Publisher
- Wiley
- Published
- 2017-04-12
- Volume
- 65
- Issue
- 7
- Pages
- 1597-1608
- ISSN
- 0002-8614 (ISSN-L)
- 1532-5415
- OpenAlex
- W2607455902
- Cited by
- 174
- References
- 153
- Citations by year
- 2026: 10 · 2025: 13 · 2024: 18 · 2023: 17 · 2022: 24 · 2021: 43 · 2020: 25 · 2019: 12 · 2018: 11 · 2017: 1
- FWCI
- 3.45
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of the American Geriatrics Society (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Canadian Institutes of Health Research (CIHR KRS‐250478)
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Keywords
- care transitions, hospital-to-primary care transition, older adults, chronic disease, discharge planning, hospital readmission, emergency department visits, mortality, self-management education, quality of life, care coordination
- MeSH terms
- Transitional Care, Chronic Disease, Hospitalization, Humans, Patient Discharge, Patient Education as Topic, Primary Health Care, Quality of Life, Self Care, Randomized Controlled Trials as Topic
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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