Leithaus Merel, Beaulen Audrey, de Vries Erica, Goderis Geert, Flamaing Johan, Verbeek Hilde, Deschodt Mieke
Academic Center for Nursing and Midwifery, Department of Public Health & Primary Care, KU Leuven, BE.
Department of Health Services Research, Maastricht University, NL.
Int J Integr Care. 2022 Jun 29;22(2):28. doi: 10.5334/ijic.6447. eCollection 2022 Apr-Jun.
Frail older adults frequently experience transitions from hospital to home due to their complex care needs. Transitional care models (TCMs) are recommended to tackle adverse outcomes in frail patients. This review summarizes the use of integrated care components in addressing transitional care from hospital to home, provides an overview on reported outcomes and describes the impact of identified components on the outcomes hospital readmission and emergency department visit.
This study is part of the European TRANS-SENIOR project. PubMed, CINAHL and Embase were searched for studies in English, German and Dutch that describe a TCM for frail older patients including both pre- and post-discharge components.
Seventeen studies, covering 15 TCMs were included. All TCMs describe a person-centred, tailored, pro-active and continuous transitional care service. Components like a small sized care team, intensive follow-up, shared decision making and informal caregiver involvement are likely to be associated with reduced hospital readmission and ED visits. Twenty-seven transitional care outcomes were reported: 19 service outcomes, six patient outcomes and two provider outcomes.
Heterogeneity in content and outcomes complicates between-study comparison, yet several components were identified that improved care outcomes. Patient and provider outcomes should be included in future research.
体弱的老年人由于其复杂的护理需求，经常经历从医院到家庭的过渡。推荐采用过渡性护理模式（TCMs）来解决体弱患者的不良结局。本综述总结了综合护理组件在解决从医院到家庭的过渡性护理中的应用，概述了报告的结局，并描述了已确定的组件对医院再入院和急诊就诊结局的影响。
本研究是欧洲TRANS-SENIOR项目的一部分。在PubMed、CINAHL和Embase数据库中检索了用英文、德文和荷兰文撰写的研究，这些研究描述了针对体弱老年患者的过渡性护理模式，包括出院前和出院后的组件。
纳入了17项研究，涵盖15种过渡性护理模式。所有过渡性护理模式都描述了以患者为中心、量身定制、积极主动且持续的过渡性护理服务。诸如小型护理团队、强化随访、共同决策和非正式照护者参与等组件可能与降低医院再入院率和急诊就诊次数有关。报告了27项过渡性护理结局：19项服务结局、6项患者结局和2项提供者结局。
内容和结局的异质性使研究间的比较变得复杂，但已确定了几个可改善护理结局的组件。未来的研究应纳入患者和提供者结局。
