Patient- and family-centred care transition interventions for adults: a systematic review and meta-analysis of RCTs

Abstract

Although patient centredness is part of providing high-quality health care, little is known about the effectiveness of care transition interventions that involve patients and their families on readmissions to the hospital or emergency visits post-discharge. This systematic review (SR) aimed to examine the evidence on patient- and family-centred (PFC) care transition interventions and evaluate their effectiveness on adults’ hospital readmissions and emergency department (ED) visits after discharge. Searches of Medline, CINAHL, and Embase databases were conducted from the earliest available online year of indexing up to and including 14 March 2021. The studies included: (i) were about care transitions (hospital to home) of ≥18-year-old patients; (ii) had components of patient-centred care and care transition frameworks; (iii) reported on one or more outcomes were among hospital readmissions and ED visits after discharge; and (iv) were cluster-, pilot- or randomized-controlled trials published in English or French. Study selection, data extraction, and risk of bias assessment were completed by two independent reviewers. A narrative synthesis was performed, and pooled odd ratios, standardized mean differences, and mean differences were calculated using a random-effects meta-analysis. Of the 10,021 citations screened, 50 trials were included in the SR and 44 were included in the meta-analyses. Care transition intervention types included health assessment, symptom and disease management, medication reconciliation, discharge planning, risk management, complication detection, and emotional support. Results showed that PFC care transition interventions significantly reduced the risk of hospital readmission rates compared to usual care [incident rate ratio (IRR), 0.86; 95% confidence interval (CI), 0.75–0.98; I² = 73%] regardless of time elapsed since discharge. However, these same interventions had minimal impact on the risk of ED visit rates compared to usual care group regardless of time passed after discharge (IRR, 1.00; 95% CI, 0.85–1.18; I² = 29%). PFC care transition interventions containing a greater number of patient-centred care (IRR, 0.73; 95% CI, 0.57–0.94; I² = 59%) and care transition components (IRR, 0.76; 95% CI, 0.64–0.91; I² = 4%) significantly decreased the risk of patients being readmitted. However, these interventions did not significantly increase the risk of patients visiting the ED after discharge (IRR, 1.54; CI 95%, 0.91–2.61). Future interventions should focus on patients’ and families’ values, beliefs, needs, preferences, race, age, gender, and social determinants of health to improve the quality of adults’ care transitions.

Introduction

Adults’ transitions between health care settings are frequent, complex, fragmented, and risky [1–3]. In the first days and weeks following hospital discharge, many experience medication-related problems, hospital readmissions, emergency department (ED) visits, or even death [4–7]. According to studies conducted among surgical and medical patients in Europe, Asia, and North America, 9.8–50% of readmissions within 30 days [8, 9], 17.8% of readmissions within 90 days [10], and 30.7% of readmissions within 1 year, are preventable [5]. Suboptimal care transitions represent a significant cause of preventable readmissions [11]. As these contribute to increasing the health care expenditures, the quality-of-care transitions and their impact on health care outcomes and cost remain a growing concern.

Indicators for quality health care, namely effectiveness, efficiency, safety and risk, timeliness, equity, and patient-centred care (PCC), are endorsed by many countries [12–14] to guide the provision and evaluation of optimal care transitions. PCC encompasses holistic, collaborative, and responsive care [15]. According to the World Health Organization (WHO) [16], quality health services should translate into the provision of care that meets individual preferences, needs, and values. Since both patients and families are important allies for quality and safety in healthcare, a patient- and family-centred approach to care that ‘is grounded in mutually beneficial partnerships among healthcare providers, patients, and families, and its goal is to ‘promote the health and well-being of individuals and families’ is warranted during care transitions [17]. Furthermore, Burke et al. [18] have proposed 10 domains for (ideal) care transitions, for example monitoring and managing symptoms after discharge; patient education; outpatient follow-up; and communication of accurate, timely, clear, organized information.

Several reviews have examined care transitions from hospital to home [19–25]. However, to our knowledge, only one has included interventions specifically involving patients’ families [21]. This review described family-centred transition processes, from US EDs to home, found in randomized controlled trials (RCT), cohort studies, case–control studies, and among paediatric and adult populations. It reported intervention effectiveness for outcomes such as patient health, knowledge, health care utilization, and cost. However, it lacked a comprehensive searching approach, a quality appraisal of included studies, or a meta-analysis of the literature [26].

This systematic review (SR) examined evidence on the effectiveness of either patient- or family-centred care (PFC) transition interventions or PFC transition interventions compared to usual care in decreasing adult hospital readmissions and ED visits after discharge (hospital to home).

Methods

Research design and methodology

This SR and meta-analysis were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [27] and were conducted based on methods recommended by Cochrane’s Handbook for Systematic Reviews of Interventions [28]. A SR protocol was developed and registered in PROSPERO (CRD42017067990), and then published [29].

Protocol amendments

Due to a large amount of data gathered, herein we report on a SR, and meta-analysis conducted to answer the following broad question: ‘Are PFC care transition interventions offered to adults during their transition from the hospital to home effective in decreasing unplanned hospital readmissions and ED visits?’. A separate manuscript focuses on the effectiveness of these interventions on diverse patient-oriented outcomes [30].

Eligibility criteria

Population/participants

This SR considered studies on hospital to home care transitions of patients ≥18 years of age. Studies conducted among adults discharged to acute care settings or specialty nursing facilities, and those examining transitions from the ED to home were excluded. Studies related to paediatrics, obstetrics, gynaecology, psychiatric, and mental health services were also excluded.

Interventions and comparators

Studies assessing the effectiveness of PFC care transition interventions provided during or after a hospitalization were included. Specifically, interventions with at least one element from each of the components (holistic, collaborative, and responsive care) of the PCC framework [15] were included. Those focusing on either the patient or their family/caregiver or on both the patient and the family were included. Examples of interventions included discharge planning, needs assessment, medication reconciliation, telephone follow-up, home visits, and patient/caregiver education. The comparators of interest included usual care, simplified intervention, or no other intervention.

Outcome measures

Study outcomes covered unplanned hospital readmissions and ED visits at 1, 3, 6 months, and ≥1 year post-discharge.

Types of studies

Only cluster-, pilot-, or RCTs published in English or French were included. Non-randomized experimental and qualitative studies were excluded.

Search strategy

Eligible references were identified from a systematic search conducted in Medline, CINAHL, and Embase. The search strategy was developed by an experienced health sciences librarian (O.D.). The search terms focused on continuity of patient care, care transition, and patient-centred care. An initial search was created and ran in 2016, with a recent search strategy updated up to and including 14 March 2021. The Medline search strategy is described in Supplementary Data File 1. References were compiled, and duplicates were removed, using EndNote X9 [31]. The final set of citations was exported into the Covidence SR software for screening, full-text review, risk of bias assessment, and data extraction [32].

Study selection

Two reviewers (M.C., A.P.) screened 15 titles and abstracts together, then independently screened the remaining references according to eligibility criteria. Unclear references were included for full-text screening. Two reviewers (M.C., A.P.) screened 15 full-text references together, then independently reviewed the remaining references for inclusion in the review. During this process, a third reviewer (J.C.) arbitrated conflicts. The study selection process was summarized using the PRISMA flow diagram [27].

Data extraction

Two reviewers (M.C., A.P.) independently extracted and organized data using a previously piloted spreadsheet. The following were extracted: first author’s last name, year of publication, full reference, country, study aim, patient eligibility criteria, groups sample size, total sample size, format of the intervention, PCC elements [i.e. (i) comprehensively assess patients’ condition including physical, emotional, social, and spiritual domains of health, (ii) assess patient’s understanding of presenting the problem, (iii) assess patient’s health values and goals, (iv) identify patient’s concerns and/or needs, (v) monitor or reassess patient’s needs, (vi) provide interventions/services to patient that address all domains of health including physical comfort and emotional support, (vii) provide information regarding health promotion, illness prevention, or lifestyle change to patient, (viii) provide information on disease and self-management to patient, (ix) support patient decision making—share information in a complete and unbiased way regarding condition, prognosis, treatment, (x) explore and respect patient’s beliefs about the problem and specific health concerns, (xi) promote discussion with patient to find a common understanding of what the problem is, (xii) explain to patient the treatment options and self-management strategies available to manage the problem, (xiii) provide complete, accurate and unbiased information about the nature of each option, and associated risks, benefits, potential outcomes, and uncertainty, (xiv) answer questions patient may have about his/her care, (xv) assess patient’s preferences for treatment or self-management, (xvi) provide the chosen treatment option or self-management strategy, (xvii) provide instructions to patient on how to apply treatment option or self-management strategy in daily life, (xviii) provide support, as needed, to patient for the application of treatment option or self-management strategy in daily life, (xix) explore with the patient who he/she wants to be involved in his/her care, (xx) incorporate the patient and family in patient care, (xxi) respond to patient’s needs, beliefs, values, and preferences, (xxii) modify the type, mode of delivery or dose of treatment or self-management strategy to be consistent with patient’s needs and preferences, (xxiii) identify changes in patient’s condition or feeling and act upon them, (xxiv) take time to answer patient questions, (xxv) make sure patient has what he/she needs with regards to his/her health care, (xxvi) make sure patient has what he/she needs with regards to community resources, and (xxvii) comfort the patient when needed], ITC domains [i.e. (a) outpatient follow-up, (b) monitoring and managing symptoms after discharge, (c) coordinating care among team members, (d) enlisting help of social and community supports, (e) educating patients to promote self-management, (f) medication safety, (g) availability, timeliness, clarity, and organization of information, (h) complete communication of information, and (i) discharge planning], provider(s) involved, description of control intervention, length of follow-up period, results of post-discharge unplanned hospital readmissions and results of post-discharge unplanned ED visits. Data were extracted from the studies or provided by authors on request.

Risk of bias assessment

The Cochrane Risk of Bias Tool [29] integrated within the Covidence SR software [32] was used. Two reviewers (M.C., A.K.) independently evaluated each included study by assessing the domains of sequence generation, allocation concealment, blinding of outcome assessment, missing outcome data, selective outcome reporting, and other sources of bias. Domains were evaluated as ‘low’, ‘unclear’, or ‘high’. A third reviewer (J.C.) was available to provide arbitration during reviewer disagreements.

Data analysis

The Cochrane Review Manager 5.4 (RevMan) was used to conduct the meta-analysis [33]. The appropriateness of conducting such a meta-analysis was evaluated by first assessing the clinical and methodologic homogeneity of all studies and identifying outlying studies. Due to variability in the reporting format for continuous outcomes, random effects inverse variance models were used to estimate standardized mean differences (SMD) comparing the PFC and usual care groups for post-discharge hospital readmissions and ED visits [29]. Similar models were used to estimate the pooled odds of post-discharge unplanned hospital readmissions and ED visits among PFC care transition interventions compared with usual care. Summary estimates were reported along with 95% confidence intervals (CI). Statistical heterogeneity was evaluated in consideration of both the Cochrane Q test and the I² measure [34]. In addition to analysing outcomes separately according to their original reporting formats (e.g. number of patients per group with the event, mean number of events per patient), we also converted related outcome measures to a common format to allow for incidence rate ratio (IRR) analyses. Numbers of events were taken as raw data or approximated in cases where the mean number of events per patient was reported. Total person-time per group was estimated using each study’s maximum follow-up time and the number of patients in the study groups.

Subgroup analyses were conducted according to follow-up duration, PCC elements (i.e. low = 0–3 elements, moderate = 10–17 elements, and high = 18–25 elements), and ITC domains (low = 1–3 domains, moderate =4–6 domains, and high = 7–9 domains) targeted in the transition interventions.

Findings of trials with insufficient data were excluded from the meta-analysis and were aggregated based on the similarity of interventions and presented in a narrative synthesis.

Results

Extent of evidence identified

Following the removal of duplicates, the search yielded a total of 10 021 unique citations for review. Following title and abstract screening, 674 citations were retained for full-text screening. Fifty references were included in this SR; see Supplementary Data File 2 for the study selection process. Supplementary Data File 3 lists the citations excluded during full-text screening (n = 624), grouped by reason for exclusion.

Study characteristics

Characteristics of the 50 included RCTs (n = 13 985 participants) are shown in Table 1. These studies were published in English between 1993 and 2021 in peer-reviewed journals and mostly conducted (n = 23) in the USA [35–57]. Sample sizes ranged from 26 to 1390 participants. The trials included adults who had at least one active chronic condition or who were admitted to a general medicine, general surgery, geriatric, neurosurgery, orthopaedic, or urology unit.

Table 1.

Characteristics of studies.

Citations’ first author, year of publication	Country	Sample size	Diagnosis/Specialty	Outcomes	Data source	Included in meta-analysis
Aboumatar, 2019	United Stated of America (USA)	240	COPD	Hospital Readmissions and ED visits	Medical record review	Y
Al-Hashar, 2018	Oman	622	Admitted to medical wards	Hospital Readmissions and ED visits	Patients’ self-report	Y
Altfeld, 2012	USA	720	Admitted for an inpatient hospitalization	Hospital Readmissions	Medicare & Medicaid claims Patients’ self-report	Y
Andersen, 2000	Denmark	155	Acute stroke	Hospital Readmissions	Data from the Danish Central Person Register, the City of Copenhagen Health Administration, and the Copenhagen Hospital Corporation Further details on readmission were obtained from discharge records	Y
Balaban, 2015	USA	1510	CHF or COPD	Hospital Readmissions and ED visits	Medical record review	N
Bostrom, 1996	USA	1413	Patients from general surgery, neurosurgery, orthopaedic, general medicine, and urology units	Hospital Readmissions	Medical record review	Y
Boter, 2004	Netherlands	486	First admission for a stroke (TIA or ischaemic stroke, primary intracerebral haemorrhage, or subarachnoid haemorrhage)	Hospital Readmissions	Not mentioned	Y
Bronstein, 2015	USA	89	Patients admitted to unmentioned inpatient units	Hospital Readmissions	Medical record review	Y
Burns, 2014	USA	423	CHF, COPD or pneumonia	Hospital Readmissions and ED visits	Medical record review	Y
Coleman, 2006	USA	750	At least one of 11 diagnoses, including stroke, CHF, CAD, cardiac arrhythmias, COPD, DM, spinal stenosis, hip fracture, PVD, DVT, and PE	Hospital Readmissions	Medical record review	N
Collinsworth, 2018	USA	308	COPD	Hospital Readmissions and ED visits	Medical record review	Y
Courtney, 2009	Australia	122	Medical diagnosis	Hospital Readmissions	Medical record review	N
Cui, 2019	Australia	96	CHF, with left ventricular ejection fraction of ≤45%	Hospital Readmissions	Medical record review and Patients’ self-report	Y
Davis, 2012	USA	125	CHF	Hospital Readmissions	Medical record review	Y
Fors, 2018	Sweden	243	COPD or CHF	Hospital Readmissions	Not mentioned	Y
Hanssen, 2009	Norway	288	AMI	Hospital Readmissions	Medical record review	Y
Harrison, 2002	Canada	192	CHF	Hospital Readmissions and ED visits	Medical Outcome Study Short Form (SF-36)	Y
Henschen, 2022	USA	151	Not mentioned	Hospital Readmissions and ED visits	Medical record review	Y
Hu, 2020	China	220	Recipient of a primary allograft kidney transplantation	Hospital Readmissions and ED visits	Not mentioned	Y
Huang, 2005	Taiwan	126	Hip fractures due to falling	Hospital Readmissions	Medical record review	Y
Kangovi, 2014	USA	446	General medicine service	Hospital Readmissions	Patients’ self-report	Y
Kazemi Majd, 2021	Iran	120	CHF	Hospital Readmissions	Medical record review and Patients’ self-report	Y
Lainscak, 2013	Slovenia	253	Acute exacerbation of COPD with reduced pulmonary function	Hospital Readmissions	Medical record review and Patients’ self-report	Y
Laramee, 2003	USA	234	CHF, moderate-to-severe left ventricular dysfunction or pulmonary congestion	Hospital Readmissions	Medical record review	Y
Lembeck, 2019	Denmark	537	Any diagnosis from the Medical, Geriatric, Emergency, Surgical or Orthopaedic departments	Hospital Readmissions	Data from the Ministry of Health	Y
Li, 2021	USA	407	Not mentioned	Hospital Readmissions	Family care givers’ (FCG) self-report	Y
Liang, 2021	Taiwan	200	Not mentioned	Hospital Readmissions and ED visits	Medical record review	Y
Lindhardt, 2019	Denmark	330	Not mentioned	Hospital Readmissions	Medical record review	Y
Lisby, 2019	Denmark	200	Medical conditions (non-surgical)	Hospital Readmissions and ED visits	Medical record review	Y
Lopez Cabezas, 2006	Spain	134	CHF	Hospital Readmissions	Not mentioned	Y
Magny-Normilus, 2021	USA	180	Type 2 DM on medicine or cardiology units	Hospital Readmissions and ED visits	Medical record review and Patients’ self-report	N
Naunton, 2003	Australia	121	Medical units, with at least two chronic medical conditions (including at least one of CHF, ischaemic heart disease, COPD or DM)	Hospital Readmissions	Medical record review	Y
Naylor, 1994	USA	401	Selected medical (CHF and angina/AMI) and surgical (CABG and cardiac valve replacement) diagnostic-related groups (DRG)	Hospital Readmissions	Not mentioned	Y
Naylor, 1999	USA	363	Multiple, active, chronic health problems or history of depression	Hospital Readmissions and ED visits	Not mentioned	Y
Naylor, 2004	USA	239	CHF	Hospital Readmissions and ED visits	Patients’ medical records and bills	Y
Nguyen, 2018	Vietnam	166	Either unstable angina or AMI	Hospital Readmissions	Patients’ self-report	Y
Nucifora, 2006	Italy	200	CHF	Hospital Readmissions	Medical record review	Y
Oliveira-Filho, 2014	Brazil	61	CVD	Hospital Readmissions	Patients’ self-report	Y
Ong, 2016	USA	1437	CHF	Hospital Readmissions	Hospitalization data, combined with California’s inpatient discharge data for hospitalizations at non study sites obtained from the California Department of Public Health Office of Statewide Health Planning and Development.	Y
Pearson, 2006	Australia	528	Medical or surgical unit	Hospital Readmissions	Medical record review	Y
Piette, Striplin, Aikens, 2016	USA	284	CHF, stroke, CAD, arrhythmia, COPD, PVD, DVT, PE, pneumonia, type 2 DM, UTI, gastroenteritis, or asthma	Hospital Readmissions	Medical record review	N
Piette, Striplin, Fisher, 2020	USA	283	CHF, stroke, CAD, COPD, PVD, pneumonia, type 2 DM, UTI, gastroenteritis, or asthma	Hospital Readmissions	Patients’ medical and billing records	N
Sales, 2013	USA	137	CHF	Hospital Readmissions	Medical record review	Y
Schneider, 1993	USA	54	CHF	Hospital Readmissions	Medical record review	Y
Schnipper, 2021	USA	1679	Admitted to medical and surgical services	Hospital Readmissions	Medical record review and patients’ self- report	Y
Shahrokhi, 2018	Iran	72	Glasgow Coma Scale (GCS) score of 11–15 on discharge, hospitalized for the first time after trauma, without known UTI or respiratory infection, Grade 3 and 4 pressure ulcers, DM, and patients without thoracostomy and percutaneous endoscopic gastrostomy	Hospital Readmissions	Not mentioned	Y
Tu, 2020	China	270	Uncontrolled hypertension at admission; and diagnosis of type 2 DM	Hospital Readmissions and ED visits	Hospital health records, community health centre records (IG) or outpatient specialist clinics (CG)	Y
Van Spall, 2019	Canada	2494	CHF	Hospital Readmissions and ED visits	Not mentioned	Y
Wu, 2019	China	150	AMI	Hospital Readmissions	Patients’ self-report	Y
Zhao, 2009	China	220	Angina or AMI	Hospital Readmissions	Patients’ self-report	Y

COPD, chronic obstructive pulmonary disease ; CHF, congestive heart failure; TIA, Trans-ischaemic attack; CAD, coronary artery disease; DM, diabetes mellitus; PVD, peripheral vascular disease; DVT, deep vein thrombosis; PE, pulmonary embolism; AMI, acute myocardial infarction; CABG, coronary artery bypass graft; UTI, urinary tract infection; CVD, cardio vascular disease.

Study interventions

While 50 studies were included in this SR, three trials included two PFC care transition interventions [38, 58, 59], for a total of 53 unique interventions. Table 2 provides an overview of the characteristics of the included interventions. Types of PFC care transition interventions varied according to the interventions’ target audience, involvement of patients and families, duration, implementation setting, mode of delivery, implementer and components of PCC and ITC.

Table 2.

Characteristics of the interventions.

Citations’ first author, year of publication	Name, title, or short sentence describing the intervention	Aim/goal/purpose of intervention	Materials (physical or informational)	Procedures (activities)	Target	Involvement of patients/families	Mode of delivery	Setting (where/locations)	Timing and doses (when and how many times)	Tailoring/personalized/individualized	Modification
Aboumatar, 2019	Three- month program to help patients and their family caregivers with long-term self-management of COPD	To evaluate whether a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers can improve outcomes.	Standardized tools	The program was delivered during a series of sessions held at the hospital and after discharge via home visit or telephone	Patient	Engaging the family/caregivers in the disease management Assessing the family/caregivers’ needs at discharge Co-developing care transition intervention with caregivers	Hospital and home visits and phone calls	Hospital and home	Duration of 3 months	Yes	No
Al-Hashar, 2018	Medication reconciliation intervention	To investigate the impact of a medication reconciliation and counselling intervention on admission and on discharge on the rate of preventable ADEs and healthcare use at 30 days following hospital discharge	Written information, Institute for Safe Medication Practices, Medication list	Medication reconciliation with patient via interview Patients were informed that they would receive a phone call 1 month post discharge to discuss their experience with their medications.	Patient	Targeting education on medications	Interview Written information Phone call	Hospital and home	During hospitalization and up to 1 month after discharge	Yes	No
Altfeld, 2013	Enhanced Discharge Planning Program	Identify needs encountered by older adult patients after hospital discharge Assess the impact of a telephone transitional care intervention on stress, health care utilization, readmissions, and mortality	Individualized plan, written information	The intervention group participants received the telephone-based Enhanced Discharge Planning Program intervention that included biopsychosocial assessment and an individualized plan following program protocols to address identified transitional care needs	Patient	Assessing their needs related to stress management (their own and the patient’s) Providing emotional support to caregiver	1) Verbal information 2) Phone call 3) Home visit, if necessary	Hospital and home	At discharge and 30 days post-discharge	Yes	No
Andersen, 2000	INT1-HVP (physician intervention) and INT2-PI (physiotherapist intervention)	To evaluate follow-up interventions after completed inpatient rehabilitation that focused on social and psychological adjustment, in preventing readmission, reduce the mortality rate and postpone institutionalization.	Written instructions	INT1-HVP The physician intervention consisted of three 1-hour home visits (at 2, 6, and 12 weeks after discharge). These visits focused on early detection and treatment of complications, maintenance of functional capacity, and psychological and social adjustment to a new life with stroke-related disability. INT2-PI Patients in this group received instruction and reeducation by the hospital physiotherapist during a 6 week period immediately after discharge. The visits took place in the patient’s home; frequency was determined by the physiotherapist and was adjusted to the patient’s needs.	Patient, families, caregivers	Engaging the family/caregivers in the disease management and rehabilitation care Engaging the family/caregivers in the discharge process Targeting education on the disease	INT1-HVP: Home visits, Phone calls (if needed) INT2-PI: Home visits	Home	INT1-HVP 2, 6, 12 weeks INT2-PI 6 weeks	Yes	No
Balaban, 2015	The Patient Navigator Intervention	Determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients	Verbal information	PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management	Patient	Connecting with family/caregivers during follow-ups Assessing the family/caregivers’ needs at discharge	Verbal information Hospital (inpatient) visit Phone calls	Hospital and home	30 days post-discharge	Yes	No
Bostrom, 1996	The Telephone Nursing Care Link Project	To compare Nurse-initiated call (NIC) and patient-initiated call (PIC) systems with patients who had no follow-up call and analyse their effectiveness	NIC: Verbal information PIC: Written information (brochure)	One group of patients was called by nurses 2–3 days after discharge; another group received a brochure describing a nurse-run telephone service they could call. These nurses asked each patient if they had any questions about their post-discharge care and if they experienced any difficulties in their transition to home. Questions were answered by the nurse either at that time or in a follow-up call after consultation with another health care provider.	Patient	Not mentioned	NIC: Phone call PIC: Written information & Phone call if needed	Home	NIC: 2–3 days post-discharge PIC: As needed (up to 3 months after discharge)	Yes	No
Boter, 2004	Outreach care	To assess the effectiveness of an outreach care program on dissatisfaction with care and quality of life.	Standardized checklist on risk factors for stroke, consequences of stroke, and unmet needs for stroke services Caregiver’s checklist Brochure	The outreach care consisted of three telephone calls and one home visit within 5 months after discharge by 1 of 13 stroke nurses. Nurses supported patients and carers according to their individual needs (eg, by giving information or reassurance) or, when the presented problem required additional care or exceeded the nurses’ expertise, advised patients or carers to contact the general practitioner.	Patients and caregivers	Assessing the family/caregivers’ needs at discharge Supporting and advising them on how to solve the problems themselves or cope with them	Brochure, phone call or home visit	Hospital and home	Three nurse-initiated telephone contacts (1–4; 4–8; and 18–24 weeks after discharge) and a visit to the patients in their homes (10–14 weeks after discharge)	Yes	No
Bronstein, 2015	Social worker-led care coordination intervention	To assess the efficacy of social work-led care coordination for stroke patients post-hospitalization and post-rehabilitation & within-30-day readmission rates.	1) Verbal information through phone call and home visit 2) Verbal information through phone call 3) Verbal or written information through educational monthly meetings held at the hospital.	The intervention assisted primarily low-income patients in addressing barriers to their remaining at home, including financial constraints, lack of knowledge about the role of their PCP, accessing and taking prescribed medications, and accessing necessary transportation for both medical follow-up care and quality-of-life activities. The interns conducted an individualized needs assessment, identifying medication concerns, transportation issues, home care needs, home safety concerns, and behavioural barriers to follow-up care and activities post-discharge via phone call and home visits.	Patient	Not mentioned	1) Verbal information through phone call and home visit 2) Verbal information through phone call 3) Verbal or written information through educational monthly meetings held at the hospital.	Hospital and home visits	Home follow-up phone call within 3–5 days post-discharge. After that, a home visit was scheduled and paid between days 7 and 14. A final phone call was made at approximately day 21 post-discharge	Yes	No
Burns, 2014	Inpatient introductory visit and weekly post-discharge telephonic support for 4 weeks to assist patient in coordinating medical visits, obtaining, and using medications, and in self-management	To evaluate the feasibility of a community health workers (CHW) intervention to reduce inpatient readmissions within 30 days of discharge for medical patients at high risk of readmission.	Verbal information, telephone interpreter	CHW participation in the hospital discharge process; semi-structured CHW outreach calls to patients on at least a weekly basis to elicit patient concerns; and liaison calls, as needed, to primary care nurses to assist in scheduling or to respond to patient concerns. A telephone script for the outreach calls prompted the CHW to address topics such as reminders and transportation assistance for upcoming appointments, barriers to obtaining medications, concerns that might require nurse intervention and poor understanding of self-management instructions.	Patients and caregivers	Supporting the family during care transition	1) Verbal information giving (hospital visit) before discharge in the hospital 2) Verbal information 3) Phone calls on at least a weekly basis	Hospital and home	30 days after discharge	Yes	No
Coleman, 2006	Care Transitions Intervention	To test whether this same intervention, designed to encourage older patients and their caregivers to assert a more active role in their care transitions, can reduce rates of rehospitalization.	Verbal and written information Inpatient, phone, and home visits	Hospital visit: Discuss importance of knowing medication and having a system in place to ensure adherence to regimen Explain the patient hospital record (PHR) Recommend primary care provider follow-up visit Discuss symptoms and drug reactions Home visit: Reconcile pre-hospitalization and post-hospitalization medication lists Identify and correct discrepancies Review and update the PHR Review discharge summary Encourage patient to update and share PHR with primary care provider or specialist at follow-up visits Emphasize importance of follow-up visit and need to provide primary care provider with recent hospitalization information Practice and role-play questions for primary care provider Assess condition Discuss symptoms and adverse effects of medications Follow-up telephone calls Answer remaining medication questions Remind patient to share PHR with primary care provider or specialist Discuss outcome of visit with primary care provider or specialist Provide advocacy in getting appointment, if necessary Reinforce when primary care provider should be telephoned	Patients and caregivers	Encouraging family/caregivers to participate in updating the patient’s health condition Ensuring their presence Teaching self-care to family/caregivers Connecting with them during follow-ups	Verbal and written information Inpatient, phone, and home visits	Hospital and home	The transition coach first met with the patient in the hospital before discharge to establish initial rapport, to introduce the personal health record, and to arrange a home visit, ideally within 48–72 h after hospital discharge. Following the home visit, the transition coach maintained continuity with the patient and caregiver by telephoning three times during a 28-day post-hospitalization discharge period.	Yes	No
Collinsworth, 2018	COPD Chronic Care (CCC) education program	To assess the feasibility of a registered respiratory therapist (RRT)-led CCC program and determine the impact of the CCC program on patient outcomes, including hospital readmissions and patient activation.	Verbal and written information	The COPD education and self-management planning took place in the hospital and lasted 15–30 min. These strategies included further discussions of COPD symptoms, medication management, appropriate diet and nutrition, stress and coping, and smoking cessation activities. The RRT would then help the participants to create a COPD self-management plan. These patients also received follow-up phone calls.	Patients	Not mentioned	Inpatient meetings and phone calls	Hospital and home	15–30 min session prior to discharge, and follow-up phone calls lasting 5–10 min from the RRT at 3–7 days and 1-, 2-, and 6-months post-hospital discharge	Yes	No
Courtney, 2009	Older Hospitalised Patients’ Discharge Planning and In-home Follow-up Protocol	Evaluate the effect of an exercise-based model of hospital and in-home follow-up care for older people at risk of hospital readmission on emergency health service utilization and quality of life	Individualized exercise program, pedometer, resistance bands	(a) Exercise intervention An individually designed exercise program prescribed by the physiotherapist included four components: muscle stretching, balance training, walking for endurance, and muscle strengthening using resistance exercises. (b) Nursing intervention The nurse visited daily during participants’ hospital stays to address concerns, facilitate the exercise program, and oversee discharge planning. (c) Intervention after discharge Within 48 h of discharge, the nurse undertook a home visit to assess availability of support, address transitional concerns, provide advice, and support, and ensure that the exercise program could be safely undertaken at home. Extra home visits were provided if required. Weekly follow-up telephone calls were provided for 4 weeks, followed by monthly follow-up for a further 5 months. The nurse was also available for contact between 9 a.m.. and 5 p.m.. weekdays.	Patients and caregivers	Not mentioned	Hospital visit Home visits Phone calls	Hospital and home	The protocol commenced within 72 h of admission and continued throughout hospitalization, after transfer to home, and in home for 6 months.	Yes	No
Cui, 2019	Structured educational intervention	To determine the effect of a structured nurse-led education program on patient self-management, symptom control, and hospital readmission	Verbal information, tutorials, printed materials, and pictures. Printed charts were provided free of charge to record all measures during the study. Detailed exercise plans were developed.	Nursing staff provided a 1-h education session to each of the participants, after their heart failure symptoms were stabilized at the hospital. A second education session of 1 hour was provided before discharge to address any concerns or questions from the participants in relation to the self-care management measures, with families encouraged to attend to discuss patient support requirements. Community supports were contacted, and exercise plans were developed for each participant. A follow-up was completed every 4 weeks post-discharge.	Patients and families	Assessing the family/caregivers’ needs in terms of support (psychological and financial) at discharge Engaging the family/caregivers in the disease management Assessing the family/caregivers’ needs at discharge	Inpatient visits Lectures Written Phone calls	Hospital and home	One-hour education session inpatient and 1-h education session prior to discharge Follow-up was completed every 4 weeks up to 12 months post-discharge.	Yes	No
Davis, 2012	Cognitive training intervention	To evaluate the effectiveness of a tailored educational intervention designed specifically for patients with mild cognitive impairment on heart failure knowledge, self-care behaviour, and 30-day readmission rates.	Spiral workbook developed for the intervention that contained pictograms and provided areas to create a person self-care schedule, medication schedule, track future appointments, and document symptoms Audio tape from session	The study intervention was based on principles of cognitive training. The intervention focused on environmental manipulations and training compensatory strategies for working with impairments in memory and executive functioning, and on improving self-confidence related to the patients’ ability to manage their health. Environmental manipulations include altering the demands on the patient by simplifying tasks and providing external cues or prompts to initiate action.	Patients	Not mentioned	Written information, teaching sessions (one on one), Audiotape of teaching session Follow-up phone call at 24–72 h post-discharge Self-care material given	Hospital and home	Inpatient and 1 phone call 24–72 h post-discharge	Yes	No
Fors, 2018	Person-centred telephone support intervention	To evaluate the effects of a person-centred telephone support in patients with CHF and/or COPD.	Health plan	The RNs listened to the patients’ narratives and asked questions to identify and deepen their understanding of the patients’ capabilities, resources and potential for self-care. The RNs made efforts to identify patients’ wishes, potentials and discussed problem areas such as dilemmas on how to take prescribed medicines and sleeping problems. The patient and the RNs together formulated attainable goals during the 6-month-long study period. After the calls, a summary of the conversation as well as goals agreed upon were documented in a health plan which was sent by mail to the patients	Patients	Not mentioned	Phone call	Home	First telephone call 1–4 weeks after discharge. And subsequent ones up to 6 months after discharge.	Yes	No
Hanssen, 2009	Telephone follow-up intervention	Assess to what extend the telephone follow-up intervention (TFI) has a long-term effect on health-related quality of life (HRQOL), up to 18 months after discharge. And to assess the long-term effects on the secondary endpoints, smoking and exercise habits, return to work and rehospitalization due to chest pain	Verbal information	The patient follow-up included primarily responses to individual needs and support of patients’ own coping efforts with respect to lifestyle changes and risk factor reduction.	Patients	Not mentioned	Phone call	Home	Weekly nurse-initiated telephone calls were arranged for the first 4 weeks; subsequently calls were arranged 6, 8, 12 and 24 weeks after discharge	Yes	No
Harrison, 2002	Transitional Care Intervention	To evaluate whether the use of usual providers, and a reorganization of discharge planning and transition care with improved intersector linkages between nurses, could improve quality of life and health services utilization for individuals admitted to hospital with heart failure.	Education booklet and map	Evidence-based education program (PCCHF) initiated Nursing transfer letter received by Home RN Phone Outreach within 24 h of discharge Phone advice from hospital nurse Education booklet used at home Education map Community RN consult with hospital RN	Patients and families	Connecting with them after discharge Providing written teaching documentation	Written information Phone call	Hospital and home	Phone call within 24 h post-discharge	Yes	No
Henschen, 2021	The Complex High Admission Management Program	To assess the CHAMP program’s effect on hospital readmissions.	Individualized care plans, verbal information	Comprehensive care planning and inpatient, outpatient, and community visits to address both medical and social needs.	Patients	Not mentioned	Inpatient, outpatient and home visits Phone calls	Hospital and home	Care planning while inpatient Post-discharge follow-up (2 clinics help per week + community support)—up to 180 days after discharge	Yes	No
Hu, 2020	Transitional care intervention	To develop and test an innovative kidney transplant recipients (KTRs) transitional care program covering interventions at admission, during the hospital stay, predischarge, and postdischarge and utilizing WeChat and teach-back strategies to promote the safe transition for KTRs under the current health care context.	WeChat, Health self-management handbook for kidney transplant recipients, drug safety instruction sheet	Risk assessment for early readmission, health education from admission to pre-discharge, individualized discharge planning, and a telephone follow-up once per week for one month and WeChat follow-up post-discharge	Patients and caregivers	Encouraging the family/caregivers to support the patient	Written Lectures Phone calls Online support	Hospital and home	Risk assessment for early readmission, health education from admission to pre-discharge, individualized discharge planning, and a telephone follow-up once per week for one month and WeChat follow-up post-discharge (within 30 days after discharge)	Yes	No
Huang, 2005	Discharge planning intervention	Examine the effectiveness of a discharge plan in hospitalized elderly patients with hip fracture due to falling.	Verbal information Brochures Hard copy summaries detailing the plans, goal progression and ongoing concerns	The nurse collaborated with the patients, family caregivers and health care team members to design an individualized discharge plan based on the patient’s information. The intervention group received two brochures prepared by the researcher. The nurse provided direct care, education, and confirmation of learning regarding both medication and environmental safety, as well as the proper employment of assistance devices	Patients, families, and caregivers	Connecting with them during follow-ups Engaging the family/caregivers in the disease management Assessing the family/caregivers’ needs at discharge and after discharge	Hospital and home visits Phone call	Hospital and home	The initial nurse visit took place within 48 h of hospital admission and the nurse visited patients at least every 48 h during hospitalization. Three–seven days after patient discharge, the nurse made one home visit and was available for patient by telephone 7 days/week (8 a.m.–8 p.m.); once a week the nurse-initiated telephone contacts with patients or caregivers. Up to 3 months after discharge.	Yes	No
Kangovi, 2014	CHWs worked with patients to create individualized action plans for achieving patients’ stated goals for recovery.	To determine whether a tailored CHW intervention would improve post-hospital outcomes among low socioeconomic status patients.	Individualized action plan, verbal information	During and after hospitalization, CHWs provided tailored support based on patients’ goals using telephone calls, text messages, and visits.	Patient	Not mentioned	Semi-structured interview Inpatient visit Telephone calls, text messages, and home visits	Hospital and home	The CHWs provided support tailored to patient goals for a minimum of 2 weeks	Yes	No
Kazemi Majd, 2021	Information Prescription (IP)	To assess the effect of a patient centred and physician prescribed evidence-based information prescription (IP) intervention on reducing the hospital readmission and death among the HF patients.	Written information (information prescription simplified by clinical librarian) Verbal description (verbal description of the importance of IPs in understanding the physician’s diagnosis, treatment, and recommendations)	This process was done in three phases as follows: (i) prescribing information by MD/information prescription direction, (ii) dispensing IP by clinical Librarian, and (iii) approval by MD and delivering it to patient	Patient	Not mentioned	Written In person while inpatient	Hospital	Duration of the discharge planning meeting upon discharge	Yes	No
Lainscak, 2013	Discharge coordinator intervention	To test whether coordination of discharge from hospital and postdischarge care reduces hospitalizations in patients with chronic obstructive pulmonary disease (COPD).	Verbal information	The discharge coordinator assessed patient situation and homecare needs to identify any problems and specific needs to adjust the in-hospital intervention according to prespecified objectives. After discharge, patients were contacted by phone 48 h after discharge to check the process of adjustment to the home environment and to inquire about any additional needs to be met until the home visit. Final patient assessment was performed during a home visit 7–10 days after discharge when pre-scheduled intervention was completed	Patients, families, and caregivers	Engaging the family/caregivers in the disease management Providing education on the disease, the treatments and the interprofessional team Assessing the family/caregivers’ needs at discharge Actively involving caregivers in the discharge planning	Inpatient visit, phone call, home visit	Hospital and home	Assessment needs while inpatient, 48 h post-discharge phone call and final patient assessment home visit 7–10 days after discharge	Yes	No
Laramee, 2003	The intervention consisted of four major components: early discharge planning, patient and family CHF education, 12 weeks of telephone follow-up, and promotion of optimal CHF medications.	To test the effect of hospital-based nurse CHF ) case management (CM) on the 90-day readmission rate in a more heterogeneous setting.	The patient received educational materials, including a 15-page CHF booklet called Heartworks developed by personnel in the institution, weight logs, self-care activities summary sheets, computerized medication lists, and a guide for measuring sodium intake. Home scales and pillboxes were made available as needed.	Four major components were: [1] early discharge planning and coordination of care [2] individualized and comprehensive patient and family education [3] 12 weeks of enhanced telephone follow-up and surveillance, and [4] promotion of optimal CHF medications and medication doses (ACEIs or ARBs and BBs) based on consensus guidelines	Patients, families, and caregivers	Connecting with them during follow-ups Providing education to family/caregivers	Inpatients visits Written information, educational material, Verbal information Phone calls Inpatient monitoring of medication and doses	Hospital and home	Patient and/or family members received telephone calls at 1–3 days after discharge and at weeks 1, 2, 3, 4, 6, 8, 10, and 12	Yes	No
Lembeck, 2019	Single follow-up home visit	To complement the evidence concerning the effect of discharge planning by focusing on a single follow-up home visit administered to frail elderly patients living in a rural area of Denmark.	Verbal information	For intervention patients study and department nurses reviewed discharge planning the day before discharge. On the day of discharge, study nurses accompanied the patient to their home, where they met with the municipal nurse. Together with the patient they reviewed cognitive skills, medicine, nutrition, mobility, functional status, and future appointments in the health care sector and intervened if appropriate	Patients	Targeting risk factors at the patient’s home Giving informed consent if necessary.	Inpatient discharge planning meeting Home visits	Hospital and home	One home visit day one post-discharge	Yes	No
Li, 2012	Intervention to empower and Intervention to educate and inform	To test the efficacy of an intervention program—Creating Avenues for Relative Empowerment (CARE)—designed to increase family member participation in the hospital care of elderly relatives to prepare them for their anticipated post-hospital caregiver roles. For improving outcomes of hospitalized older adults and their family caregivers (FCGs)	Audio-taped and written materials containing information given during hospital stay and before discharge	Intervention to empower family caregivers to choose care activities they wish to perform in association with identified potential problems Intervention provides FCGs with two 10 min tapes and written handouts describing common complications of and older patient responses to hospitalization	Patients and caregivers	Participating in the patient’s care while in hospital Preparing the family/caregivers for the patient’s discharge Assessing the family/caregivers’ needs at discharge Filling out questionnaires about empowerment as a caregiver	Inpatient visit, Audio-taped and written materials	Hospital	Within 1–2 days after hospital admission, CARE Program FCGs were assisted to develop a plan (a Mutual Agreement) for their relatives’ hospital care, based on their abilities and preferences. Session II, initiated 1–3 days before discharge, consisted of audio-taped and written materials	Yes	No
Liang, 2021	The patients in the intervention group participated in an integrated tele-homecare program.	To evaluate the effectiveness of an integrated nurse-led tele-homecare program for patients with multiple chronic illnesses and a high risk for readmission.	Wireless transmission devices, including a one-touch smartphone, blood pressure (BP) monitor, medication dispenser, and a necklace emergency call button. Participants with diabetes were also given a glucometer to measure their blood sugar	The intervention group program offered continuous telemonitoring through wireless transmission devices and home visits. To ensure integrated program compliance and to meet patients’ medical needs, tele-homecare nurses also conducted home visits (content of care included assessment, patients’ education, nutrition and medication consultation, and medication reminders) on the discharge day (T0), 3 months after discharge (T3), and 6 months after discharge (T6).	Patients and families	Engaging the family/caregivers in the disease management Providing caregivers with education regarding patient care, mental support, and pain management	Continuous telemonitoring Home visits	Home	Tele-homecare nurses conducted home visits on the discharge day (T0), 3 months after discharge (T3), and 6 months after discharge (T6).	Yes	No
Lindhardt, 2019	Group A (n = 117): patients were informed of health problems and self-care interventions Group B (n = 116): a motivational conversation targeting activities of daily living with a home care nurse and a home visit.	To test and compare the effect of [1] a systematic discharge assessment with targeted advice and [2] a motivational interview followed by a home visit.	Intervention A: written information Intervention B: verbal information	Intervention A: This group received a brief information-based intervention comprising a report with the assessment results from the baseline measurements and oral, written, and web-based information about self-management targeted at the relevant problem areas. The municipality preventive consultant phoned the patients at home and provided information about relevant municipality activities they could join. No home care or other services were offered. Intervention B: Patients in this group took part in a motivational interview with an experienced municipality nurse, skilled in this technique. The nurse made a home visit a week after discharge to follow-up on possible problems and sent a brief narrative report to the general practitioner and the municipality preventive consultant. The municipality preventive consultant phoned the patient at home and provided the same information as in intervention A.	Patients	Not mentioned	Intervention A: written, hospital, phone call Intervention B: hospital, home visit, phone call	Intervention A: hospital and home Intervention B: hospital and home	Intervention B: home visit 1 week post-discharge	Yes	No
Lisby, 2019	The intervention consisted of [1] an assessment of the patient’s overall situation, [2] an assessment of their comprehension of discharge recommendations, [3] a simple discharge letter targeting the individual patient’s health literacy and [4] a follow-up telephone call 2 days post-discharge.	To investigate the clinical impact (e.g. readmissions, utilization of healthcare, patients’ experience of the discharge and their health-related quality of life) of a comprehensive nurse-led discharge intervention on non-surgical patients in acute medical units.	Discharge letter	The intervention consisted of four elements: [1] an assessment of the participant’s overall situation and initiation of relevant actions (Pit stop 1), [2] a dialogue with the patient focusing on the discharge recommendations provided by the physician (Pit stop 2), [3] a discharge letter targeting the patient’s health literacy and [4] a follow-up telephone call 2 days post-discharge	Patients	Not mentioned	Meeting in hospital Follow-up phone call	Hospital and home	Assessment when inpatient and phone call 2 days post-discharge	Yes	No
Lopez Cabezas, 2006	The patients assigned to the intervention group received information about the disease, drug therapy, diet education, and active telephone follow-up	To assess the efficacy of a multifactorial educational intervention carried out by a pharmacist in patients with heart failure (HF).	Written and verbal information	1. Information: the day of hospital discharge, a personal interview was performed, aimed at the patient and his caregiver, particularly dealing with the following: -Information on the disease - Diet education - Information on drug therapy 2. Telephone strengthening: - Contact telephone - Monthly during the first 6 months of follow-up, and subsequently, every 2 months, a telephone call was made to the home of the patient, as a strengthen to the intervention and to solve any doubts or problems that could have arisen	Patients and caregivers	Providing education to the patients and their caregivers.	Phone call and in person interview	Hospital and home	Visits were completed at 2, 6, and 12 months.	Yes	No
Magny-Normilus, 2021	Intensive transitional care intervention	To design, implement, and evaluate a multipronged transitional care intervention among hospitalized patients with diabetes.	Written information	1. Inpatient protocol for adjusting the discharge diabetes regimen 2. Nurse practitioner ‘discharge advocate’ (DA) to schedule follow-up appointments, prepare an after-hospital care plan, and educate patients/caregivers regarding the primary diagnosis, self-care plan after discharge, upcoming tests and appointments, danger signs to watch for, and who to contact. 3. Inpatient pharmacist counselling 4. Visiting nurse intervention 5. Phone call by the DA to patient within 48 h of discharge 6. Follow-up in a post-discharge clinic with the DA and pharmacist (who was also a certified diabetes educator) within 3 days of discharge 7. Telemonitoring of point-of-care glucose levels to the patient’s PCP or endocrinologist as appropriate 8. Follow-up with PCP or endocrinologist within 1 week of discharge.	Patients and caregivers	Assessing the family/caregivers’ needs at discharge Engaging the family/caregivers in the disease management	Written, in person visits, and via phone call	Hospital and home	Inpatient protocol Inpatient pharmacist counselling Phone call by the DA to patient within 48 h of discharge Follow-up in a postdischarge clinic with the DA and pharmacist (who was also a certified diabetes educator) within 3 days of discharge Follow-up with PCP or endocrinologist within 1 week of discharge.	Yes	No
Naunton & Peterson, 2003	Home Visit Protocol	To evaluate pharmacist-conducted follow-up at home of high-risk elderly patients discharged from hospital.	written and verbal information	Patients were visited at home by a pharmacist 5 days after discharge. The pharmacist educated patients on their medications, encouraged compliance, assessed for drug-related problems, intervened when appropriate and communicated all relevant findings to community health professionals.	Patients and caregivers	Assessing the family/caregivers’ needs at discharge Engaging the family/caregivers in the disease management Assuring family/caregiver would provide increased support to patient Connecting with them during follow-ups	written, in person visits	Home	Pharmacist home visit 5 days post-discharge	Yes	No
Naylor, 1994	Patients and caregivers in the intervention group received the hospital’s routine plan and a comprehensive, individualized discharge planning protocol developed specifically for elderly patients and implemented by gerontologic clinical nurse specialists	To determine the effects of a comprehensive discharge planning protocol, designed specifically for the elderly and implemented by nurse specialists, on patient and caregiver outcomes and cost of care.	Written discharge plan, verbal information	1. In hospital visit at admission and discharge 2. Visit at admission 3. Visit every 48 h to implement the plan through patient and caregiver education. 4. Summaries of the discharge plan distributed to health care team members and caregiver. 5. Visit every 48 h and before discharge to evaluate the discharge plan. Nurse specialist available 7 days a week for questions from patients or caregivers for up to 2 weeks after discharge. 6. Telephone calls	Patients, families, and caregivers	Providing education to the patients and their caregivers. Assessing the family/caregivers’ needs at discharge Validating the education provided Connecting with them after discharge Being available to family/caregivers after discharge for questions or concerns	In person visits, phone call	Hospital and home	In hospital visit at admission and discharge. Visit every 48 h to implement the plan and calls up to 2 weeks after discharge.	Yes	No
Naylor,1999	A 3-month APN-directed discharge planning and home follow-up protocol	To examine the effectiveness of an APN-centred comprehensive discharge planning and home follow-up protocol for elders hospitalized with one of several common medical and surgical reasons for admission.	Verbal information	The intervention included all the following components: [1] a standardized orientation and training [2] use of care management strategies foundational to the Quality Cost Model of APN Transitional Care [3] APN implementation of an evidence-based protocol, guided by national heart failure guidelines and designed specifically for this patient group and their caregivers	Patients and caregivers	Engaging the family/caregivers at discharge Connecting with them during follow-ups Assessing the family/caregivers’ needs at discharge Ensuring their presence during follow-up visits Engaging the family/caregivers in the disease management Answering their questions	In person visits, and phone call	Hospital and home	Started with an initial APN visit within 24 h of index hospital admission, APN visits at least daily during the index hospitalization, at least eight APN home visits (one within 24 hours of discharge), weekly visits during the first month, bimonthly visits during the second and third months, additional APN visits based on patients’ needs, and APN telephone availability 7 days per week (8 a.m. to 8 p.m., weekdays; 8 a.m. to noon, weekends).	Yes	No
Naylor, 2004	Intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specifically for elders at risk for poor outcomes after discharge and implemented by advanced practice nurses	To examine the sustained effect of a 3-month comprehensive transitional care (discharge planning and home follow-up) intervention directed by APNs for elders hospitalized with heart failure on time to first readmission or death, total rehospitalizations, readmissions due to heart failure and comorbid conditions, quality of life, functional status, patient satisfaction, and medical costs.	Verbal information, standardized comprehensive discharge planning and home follow-up protocol	Intervention group patients and their caregivers, if available, received a standardized comprehensive discharge planning and home follow-up protocol designed specifically for elders at high risk for poor post-discharge outcomes. The protocol guided patient assessment and management and specified a minimum set of APN visits.	Patients, families, and caregivers	Assessing the family/caregivers’ needs at discharge Engaging the family/caregivers in the disease management	In person visits, written information, audiotapes of patient teaching sessions	Hospital and home	Initial APN visit within 48 h of hospital admission; APN visits at least every 48 h during the index hospitalization; at least 2 home APN visits (1 within 48 h after discharge, a second 7–10 days after discharge); additional APN visits based on patients’ needs with no limit on number; APN telephone availability 7 days per week (8 a.m. to 10 p.m. on weekdays and 8 a.m. to noon on weekends); and at least weekly APN-initiated telephone contact with patients or caregivers up to 3 months after hospital discharge.	Yes	No
Nguyen, 2018	Intervention patients received educational and behavioural interventions by a pharmacist	To assess whether a pharmacist-led intervention enhances medication adherence in patients with acute coronary syndrome (ACS) and reduces mortality and hospital readmission.	Verbal information	The multifaceted intervention comprised two counsellingsessions. At the first counselling, a pharmacist performed a 30- min in-person counselling within 1 week before discharge including: [1] assessment and giving advice on basic knowledge of ACS: definition, risk factors, possible cardiac events, and prevention; [2] assessment of past experiences of using medications, encouragement and tailored advice; [3] providing medication aids including pill organizer and drug information leaflet; [4] teaching back and correcting misunderstanding. At the second counselling, the pharmacist performed a 30 min telephone counselling within 2 weeks after discharge including: [1] assessment of general and medication-related issues patients concerning; [2] encouragement and tailored advice; [3] teaching back and correcting misunderstanding	Patients	Not mentioned	In person and via phone call	Hospital and home	First counselling by pharmacist within 1 week before discharge including and second counselling within 2 weeks after discharge	Yes	No
Nucifora, 2006	Nurse-led education programme, facilitated telephone communication and follow-up visits with an internist at 15 days, 1 and 6 months	Evaluated the effects of a heart failure (HF) management programme, which included patient education and regular outpatient contact with the HF team, on re-hospitalisation and death, optimising the few resources already available at the hospital	Verbal information, teaching booklet	The study intervention consisted of pre-discharge intensive education about HF. Three to five days after discharge the study nurse telephoned the patient to assess potential problems, to promote self-management skills and to reinforce education. Patients were encouraged to telephone the study nurse any time they experience worsening symptoms or had questions about their disease or treatment, from 8.00 to 9.00 a.m., Monday to Friday. Outpatient visits by internal medicine doctors were planned at 15 days, 1 and 6 months after discharge. During these visits doctors evaluated test results, performed a physical examination, and assessed patient’s clinical progress since discharge and patient’s adherence to prescribed therapeutic regimen.	Patients	Not mentioned	Verbal and written information, in person inpatient, outpatient visits, phone call	Hospital and home	Pre-discharge intensive education about HF. Three to five days after discharge the study nurse telephoned the patient to assess potential problems. Outpatient visits by internal medicine doctors were planned at 15 days, 1 and 6 months after discharge.	Yes	No
Oliveira-Filho, 2014	This protocol consisted of two distinct parts: patient-centred verbal instructions and written material about prescribed medications.	To assess the impact of a low-cost intervention designed to improve medication adherence and clinical outcomes in post-discharge patients with cardiovascular disease (CVD).	Written and verbal information	Enhanced medication review provided by pharmacists to patients in the intervention group on the day of discharge consisted of nine steps with mean total duration of 32 min: 1. Doctor confirms the patient’s hospital discharge and sends the outpatient prescription for analysis by the pharmacist. 2. Pharmacist transcribes data from medical records and prescription to a form specifically designed for this study. 3. Pharmacist reviews the following data for each drug: indication, dosage and schedule, treatment duration, method of use, adverse reactions, main drug–drug, and drug–food interactions. Current drug–drug interactions or other drug-related problems are communicated to the prescriber before discharge. The communicated problems did lead to an adaptation/correction of the prescription. 4. Pharmacist reviews the following data for each patient: diagnosis, age, sex, and drugs used before hospitalization. 5. After reviewing patient data, the pharmacist highlights critical points to the success of treatment after hospital discharge. 6. Main advice and schedules are written on a drug treatment card adapted as a refrigerator magnet.	Patients and families	Ensuring their presence	In person, written information	Hospital	The enhanced medication review was provided by pharmacists to patients in the intervention group on the day of discharge	Yes	No
				7. Subjects considered critical to successful treatment and schedules are discussed with the patient. In this step, the health-disease process is also discussed, as well as measures to be taken in case of a forgotten dose. 8. Instructions about drug treatment are checked with the patient. 9. Drug card and phone number are given to the patient for contact.
Ong, 2016	The intervention combined health coaching telephone calls and telemonitoring.	To evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with heart failure (HF).	Electronic equipment that collected daily information about blood pressure, heart rate, symptoms, and weight, education booklet	Pre-discharge HF education, regularly scheduled telephone coaching, and home telemonitoring of weight, blood pressure, heart rate, and symptoms	Patients	Not mentioned	In person, electronic monitoring, phone call	Hospital and home	The nurse first contacted each enrolled patient 2 or 3 days after discharge from the hospital to reinforce the predischarge health coaching topics. Subsequent telephone nurse coaching then occurred on a weekly basis during the first month after discharge. After the first month, nurse coaching telephone calls were made monthly until the end of the 6-month study period	Yes	No
Pearson, 2006	Multidisciplinary home-based intervention	To compare all-cause mortality and recurrent hospitalization during median follow-up of 7.5 years in a heterogeneous cohort of patients with chronic illness initially exposed to a multidisciplinary, homebased intervention (HBI) (n = 260) or to usual postdischarge care (n = 268)	Verbal information Written information (Reminder cards) Medication compliance devices	All HBI patients received counselling before discharge by the study nurse and/or hospital pharmacist in relation to their prescribed medications. High-risk patients received the following additional interventions: A home visit at 1 week by the study nurse and pharmacist to: [1] assess the patient’s physical, clinical and psychosocial status; [2] optimize home-medication management; [3] increase patient and/or caregiver vigilance for clinical deterioration; and [4] improve liaison with community-based services thereafter. Patients with more complex problems were referred to a community pharmacist. The patients’ primary care physician received a comprehensive report with recommendations for remedial action and long-term follow-up.	Patients and caregivers	Engaging the family/caregivers in the disease management	Inpatient and home in person visits	Hospital and home	Counselling before discharge, and a home visit 1 week after discharge.	Yes	No
Piette, Striplin, Aikens, 2020	CarePartner Program Intervention	To evaluate a mobile health intervention designed to improve post-hospitalization support for older adults with common chronic conditions.	IVR (Interactive voice response) Phone Calls Care Partners (CPs) Communication Clinical Alerts	Intervention patients received automated assessment and behaviour change calls. CarePartners received automated, structured feedback following each assessment. Clinicians received alerts about serious problems identified during patient calls	Patients and caregivers	Ensuring patient and caregiver to communicate after discharge Providing education on the role and expectations of a caregiver	Follow up automated calls (IVR)	Home	During the initial 2 weeks post-discharge, patients received up to 3 attempts to complete a daily assessment call. Call frequency was then reduced to 3 times weekly for the second 2 weeks, and then once weekly for the final 9 weeks.	No	No
Piette, Striplin, Fisher, 2020	Care Partner Program Intervention	Our primary hypothesis was that the Care Partner intervention would improve 30-day readmission rates and the combined outcome of readmission/emergency department use	IVR (Interactive voice response) Phone Calls Care Partners (CPs) Communication Clinical Alerts	Intervention patients received weekly automated assessment and behaviour change calls. CPs received structured email feedback. Outpatient clinicians received fax alerts about serious problems.	Patients and caregivers	Providing transition education Providing access to family/caregiver to receive information about the patient Providing education on the role and expectations of a caregiver Ensuring patient and caregiver to communicate after discharge	Automated IVR calls	Home	During the initial 2 weeks after discharge, patients received daily IVR calls, with up to three attempts per day. After the initial 2 weeks, patients received IVR calls three times per week for 2 weeks, and then weekly for 9 weeks.	No	No
Sales, 2013	Instructions from the volunteer staff including education before discharge from the hospital, a unique single-page discharge sheet, and post-discharge follow-up phone calls.	To evaluate the effectiveness of using trained volunteer staff in reducing 30-day readmissions of CHF patients	Written and verbal information, 1-page discharge sheet with the patient’s medication names, dosage, and frequency at which the medication should be taken were written in large letters and simple language	The interventional arm (arm A) received dietary and pharmacologic education by a trained volunteer, a follow-up telephone calls within 48 h, and a month of weekly calls	Patients and caregivers	Engaging the family/caregivers in the disease management	Written information, in person, phone calls	Hospital and home	Dietary and pharmacologic education prior to discharge, a follow-up telephone calls within 48 h, and of weekly calls up to 1 month after discharge	Yes	No
Schneider, 1993	Medication discharge planning program	To examine the effects of a medication discharge planning program on readmissions within 31 days.	Written and verbal information, information cards	Medication discharge planning to provide instruction on the requisites necessary for medication self-care.	Patients	Educating the family/caregivers at discharge regarding medications	Written and verbal information	Hospital	Medication education session prior to discharge	Yes	No
Schnipper, 2021	Multifaceted Intervention to Achieve Ideal Hospital Discharge	To develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events.	Written and verbal information	Multicomponent intervention in the 30 days following hospitalization, including inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient ‘discharge advocate’ and a primary care ‘responsible outpatient clinician,’ postdischarge phone calls, and postdischarge primary care visit.	Patients and caregivers	Engaging the family/caregivers in the disease management Assessing the family/caregivers’ needs at discharge	Hospital and home in person visits, and phone call	Hospital and home	Inpatient pharmacist–led medication reconciliation and patient counselling, postdischarge phone call, post-discharge follow-up up to 30 days following hospitalization	Yes	No
Shahrokhi, 2018	Telenursing intervention	To assess the effect of telenursing on care provided by the caregivers of patients with head trauma.	Written and verbal information, educational booklets	Phone calls were made by a telenurse. The patients’ caregivers were trained in one face to-face session, lasting for 1 h, on how to take care of patients at home and were provided with educational booklets 2 days before discharge for both groups. Then, the patients of the intervention group were followed up every week for 12 weeks through phone calls by the telenurse, who recorded the patient status checklists.	Patients and caregivers	Engaging the family/caregivers in the disease management Giving them the opportunity to connect with them after discharge	Written information provided in hospital Phone calls	Hospital and home	One face to-face session 2 days before discharge for both groups. Then, the patients of the intervention group were followed up every week for 12 weeks through phone calls.	Yes	No
Tu, 2020	A transitional care intervention for hypertension control for older people with diabetes	To evaluate the effect of a nurse-coordinated hospital-initiated transitional care programme on hypertension control for older people with diabetes in China	Verbal information	Participants in the intervention group received a 6-month hospital to home transitional care programme coordinated by discharge nurses and community nurses. The programme comprised self-management education, lifestyle changes, individualized medication treatment, structured telephone support, and primary care visits	Patients	Not mentioned	In person hospital discharge visit Follow up phone calls	Hospital and home	Provide older people with self-management support through goal setting, action planning, health education, and problem-solving in hospital discharge and during the follow-up period (6 months) in community health centres	Yes	No
Van Spall, 2019	Patient-Centred Transitional Care Services	To test the effectiveness of the Patient-Centred Care Transitions in HF transitional care model in patients hospitalized for HF.	Verbal information	Nurse-led self-care education, a structured hospital discharge summary, a family physician follow-up appointment less than 1 week after discharge, and, for high-risk patients, structured nurse home visits and heart function clinic care.	Patients and caregivers	Engaging the family/caregivers in the disease management	In person hospital visit Home visits Phone calls	Hospital and home	Nurse-led self-care education, structured hospital discharge summary, family physician follow-up appointment less than 1 week after discharge. The nurse-led visits included weekly, structured, face-to-face and telephone assessments lasting 4–6 weeks	Yes	No
Wu, 2019	The health management intervention program	To assess the effects of transitional health management on adherence and prognosis in elderly patients with acute myocardial infarction undergoing percutaneous coronary intervention (PCI).	Handbook of Transitional Health Management after PC, verbal information	The ‘Handbook of Transitional Health Management’ was distributed to patients and their families in the intervention group on the first postoperative day after PCI and explained one by one, repeatedly emphasizing the precautions during the transition period. After discharge, two follow-up methods were adopted: telephone and home visit	Patients and caregivers	Engaging the family/caregivers in the disease management Targeting post-op interventions	Written information In person hospital discharge session Follow-up phone calls	Hospital and home	The handbook was given postoperative day 1. The telephone was used to follow up once a day after discharge. If no new problems occurred for 3 days, phone calls were changed to 2 times a week for 1 month. Then, follow-up was carried out once a month up to 12 weeks.	Yes	No
Zhao, 2009	Transitional care programme	To test the effects of a postdischarge transitional care programme among patients with coronary heart disease.	Hospital visit Home visit Phone call	The study group received the post-discharge transitional care programme, which consisted of pre-discharge assessment, structured home visits and telephone follow-ups within 4 weeks after discharge	Patients	Not mentioned	In person pre-discharge in hospital visit Home visits Follow-up phone calls	Hospital and home	Nurse in hospital assessed the participant. Nurse in community continued to follow up with the participant in the community for 4 weeks. Nurse-C provided one home visit on the second day and another in the third week and made two telephone calls in the second and fourth weeks after the patient was discharged from the hospital.	Yes	No

Reported interventions were patient-centred [35–39, 42–45, 52, 56, 59–69]. Only one study reported actively involving patients’ and caregivers in the co-development of their PFC care transition intervention [35].

Interventions varied in length ranging from 1 day to 12 months, with the majority lasting up to 3 or 6 months [35, 38, 42, 44, 46, 52–54, 58, 61, 62, 67, 68, 70–74]. Most interventions were hospital- and home-based [35–37, 39–46, 48–52, 55, 57, 59, 64–82]. Some were offered in the hospital setting only [47, 56, 63, 83] and others in the home setting only [38, 53, 54, 58, 61, 62, 80].

The mode mostly used to deliver the PFC care transition interventions include hospital visits, follow-up home visits, follow-up phone calls during which either or both verbal (i.e. education sessions) and written information (i.e. brochure and booklet) was provided to patients and families. The types of care transition interventions included health assessment, symptom and disease management, medication reconciliation, discharge planning, risk management, complication detection, and emotional support. Only a few PFC interventions included the use of technology, such as audiotapes [43, 47, 51], interactive voice responses [53, 54], online support [74], text messages [45], and telemonitoring with smartphones [52, 79]. Nurses (i.e. registered nurses, advance practice nurses, and nurse practitioners), on their own or with other healthcare providers, were more often responsible for implementing the PFC care transition interventions.

The PFC care transition interventions varied in the number of included PCC elements, ranging from 3 to 14 of the possible 27 PCC elements [15] (Supplementary Data File 4). The study which included the most PCC elements (n = 14) in their PFC intervention was Naylor [51]. The most recurrent PCC component in the PFC care transition interventions was collaborative care, whereas the most recurrent PCC element was the provision of information on disease and self-management to patient and family. The interventions also varied regarding their comprehensiveness of the transition in care, according to nine of Burke and colleagues’ [18] domains of an ITC, as the advance care planning domain was excluded (Supplementary Data File 5). The ITC component that was included most often in the PFC care transition interventions was patient education and promotion of self-management. Laramee et al. [46] was the only study that included all nine ITC components.

Outcome measures

Trials measured hospital readmissions and ED visits using a combination of administrative data as well as patients’ and their family members’ reports. Most trials (n = 34) reported solely on unplanned hospital readmissions and 16 reported on unplanned hospital readmissions and ED visits (Table 1).

Findings from risk of bias appraisal

The Supplementary Data File 6 and Supplementary Data File 7 summarize the findings of our appraisal of the studies’ risk of bias.

Findings, missing data

Trials recorded outcomes on hospital readmissions or ED visits after discharge. However, 11 trials provided insufficient data. Some authors [35, 48, 64, 77] responded to inquiries for missing details (hazard ratios and 95% CIs, standard deviations for adjusted outcomes or separate data for readmissions and ED visits) and to clarify the frequency of readmissions post-discharge. Trials were excluded from the meta-analyses when authors [37, 41, 53, 54, 71, 76] were unable to provide means, standard deviations, or hazard ratios.

Findings, hospital readmissions

Hospital readmission data were reported in various formats in 44 trials (n = 17 350 participants) (Table 1). Only statistically significant results are reported below. Findings from all meta-analyses are provided in Supplementary Data File 8.

Number of patients readmitted one or more times

A meta-analysis of 10 trials (38, 39, 45, 52, 55–57, 65, 77, 82) involving 8076 participants was conducted. Analysis based on the measurement one month after discharge showed that PFC care transition interventions had minimal impact on the risk of patients being readmitted at least once compared to the usual care group (OR = 0.93; 95% CI, 0.74–1.18; I² = 46%; Supplementary Data File 8). A meta-analysis was conducted of four trials [62, 81, 83, 84] among 1011 participants assessing the number of patients readmitted at least once 1–8 years after discharge. The PFC care transition interventions significantly reduced the risk of patients being readmitted at least once compared to the usual care group (OR = 0.63; 95% CI, 0.44–0.91; I² = 32%).

Number of incidents of hospital readmissions

When combining study data across reporting formats from 24 trials [35, 36, 38, 43–46, 49–51, 59–64, 67, 72, 75, 78, 84], results from the meta-analysis showed that PFC care transition interventions significantly reduced the incidence of hospital readmission rates compared to the usual care group (IRR= 0.86; 95% CI, 0.75–0.98; I² = 73%) (Supplementary Data File 8).

Findings, ED visits after discharge

ED visits were reported in various formats in 16 trials (n = 7734 participants) [35, 37, 40, 42, 44, 48–51, 60, 65, 68, 71, 76, 77, 79, 82]. Only statistically significant results are reported here. Findings from all meta-analyses are provided in Supplementary Data File 9.

Number of patients who visited the ED after discharge one or more times

A meta-analysis of three trials [42, 68, 79] involving 778 participants was conducted. Analysis based on measurement 6 months after discharge showed that PFC care transition interventions significantly reduced the risk of patients visiting the ED compared to the usual care group (OR = 0.56; 95% CI, 0.34–0.95; I² = 51%, Supplementary Data File 9).

Number of incidents of ED visits

When combining all formats for five trials [35, 44, 46, 60, 82], results showed that PFC care transition interventions had minimal impact on the incidence of ED visits compared to the usual care group (IRR = 1.0; 95% CI, 0.85–1.18; I²= 29%; Supplementary Data File 9).

Findings, subgroups

The PFC care transition interventions which had a moderate PCC score (10–17 elements) significantly decreased the risk of patients being hospitalized compared to the usual care group (IRR= 0.73; 95% CI, 0.57–0.94; I²= 59%; Supplementary Data File 9), but had a minimal effect on their risk of visiting the ED after discharge (IRR= 1.54, 95% CI 0.91–2.61; Supplementary Data File 8). Those which scored high (7–9) on ITC domains, significantly decreased the risk of patients being hospitalized compared to the usual care group (IRR = 0.76; 95% CI, 0.64–0.91; I²= 4%; Supplementary Data File 8), but significantly increased their risk of visiting the ED after being discharged compared to the usual care group (IRR = 1.54; 95% CI, 0.91–2.61; Supplementary Data File 9).

Discussion

Statement of principal findings

PFC care transition interventions appear to significantly decrease the risk of unplanned hospital readmissions rates compared to usual care. However, these interventions seem to have minimal impact on the risk of ED visits rates compared to the usual care group, regardless of time after discharge. PFC care transition interventions with a greater number of PCC elements seem to significantly decrease the risk of hospitalization yet have a minimal impact on the risk of patients visiting the ED any time after being discharged. The PFC care transition interventions targeting a greater number of ITC domains appear to significantly decrease the risk of hospitalization; however, increase the risk of patients visiting the ED. Therefore, our findings show that it is not any particular component of the PFC interventions, but rather the PCC and ITC framework as a whole that appears to be most effective in decreasing hospital readmissions.

Strengths and limitations

This SR and meta-analysis adhered to the PRISMA guidelines [27], and the recommendations of the Cochrane’s Handbook for Systematic Reviews Interventions [29]. However, the database search was conducted ∼2.5 years prior to the manuscript submission for publication. Although a research librarian developed the search strategy, some relevant studies may not have been identified during the search process and may have been missed. Our SR found significant heterogeneity among trials in terms of the wide range of samples, interventions, usual care, and reported outcomes. Thus, we included a narrative synthesis of the outcomes to avoid biased reporting.

Interpretation within the context of the wider literature

Previous reviews have reported on care transition interventions and their effectiveness regarding patient outcomes as well as health care utilization and costs. However, they targeted surgical [22], medical [25], frail older [23], cardiac [24], and paediatric patients [21] or did not focus on PFC interventions [19, 20, 22–24]. This is, to our knowledge, the first SR and meta-analysis that assessed the effectiveness of care transition interventions involving patients and caregivers in terms of adults’ hospital readmissions and ED visits after discharge. Findings suggest that these interventions reduce adults’ risk of hospital readmission and ED visits. This contradicts Desai et al.’s [21] findings that patient- and family-tailored discharge education showed mixed results regarding 30-day hospital readmissions and ED visits. This divergence may be attributed to Desai et al.’s [21] focus on ED, lack of a framework to determine family-centredness of transition processes, and inclusion of studies conducted solely in the USA.

Implications for policy, practice, and research

The involvement of patients and families in care transition interventions may contribute to decreasing hospital readmissions and ED visits after discharge, which may lead to reducing hospitals’ operational costs. Like the WHO [85], we recommend the development and execution of national quality policies to design, implement, and evaluate care transition interventions engaging, and empowering patients and families. PFC care transition interventions are variable and cannot be standardized [86]. Such interventions need to be coherent with patients’ and families’ values, beliefs, needs, preferences, race, age, gender, and social determinants of health. Dismantling and feasibility studies are required to gain knowledge about causality between PFC intervention exposure and outcomes, as well as PFC intervention components and outcomes, and uptake of the PFC care transition interventions [87]. Moreover, process evaluations, instead of outcomes, may capture the fidelity of the PFC care transition interventions and may provide insight into which PCC component or ITC domain, in isolation or in combination, is most effective in decreasing health care utilization [25]. Finally, this review found that PFC care transition interventions including a greater number of ITC domains significantly increased ED visits after discharge regardless of time elapsed. This is consistent with Branowicki et al.’s [88] conclusions. Therefore, the use of all components of the PCC and ITC framework [15, 18] presented in this paper are key to inform future policies, practice, and research. Effective discharge planning and post-discharge follow-up allow patients to detect worrisome signs and symptoms and get medical treatments and advice, which may mean returning to the ED after discharge. Even if ED visits result in hospital readmissions, these may not adequately capture deficits in the quality of care delivered during the ED visit [89]. Therefore, like Udod et al. [90], we recommend evaluating the outcomes of care transition interventions according to Donabedian’s framework [91] by measuring patient knowledge and behaviour, patient satisfaction, and health-related quality of life [92].

Conclusions

Various interventions involving patients and families have been developed and evaluated regarding health care utilization of adults from hospital to home. This review highlights the effectiveness of such interventions in decreasing hospital readmissions compared to usual care. The current evidence supports recommending care transition interventions that include patients who are being discharged from hospital and their families in the development and evaluation of such interventions. Further research could evaluate these in terms of patients’ and families’ knowledge, and behaviour, patient satisfaction, and health-related quality of life.

Author contribution

Julie Chartrand and Chantal Backman designed the project and performed data acquisition. Orvie Dingwall designed and conducted the literature searches. Julie Chartrand, Brian Hutton, and Beverley Shea conducted the data analyses. Julie Chartrand, Mariève Chartrand, Ariane Poulin, and Anupriya Kakkar performed data interpretation. Julie Chartrand was the major contributor in writing the manuscript. All authors critically reviewed and edited the final manuscript.

Supplementary data

Supplementary data is available at IJQHC online.

Conflict of interests

Brian Hutton has previously received honoraria from Eversana Inc for the provision of methodologic advice related to SRs and meta-analysis. All other authors have no conflict of interest to declare.

Funding

Technical support was provided by health sciences, sciences, psychology, and nursing undergraduate students who were financially supported by the University of Ottawa Undergraduate Research Opportunity program and supervised by Julie Chartrand.

Data Availability Statement

Since this is a Systematic Review, the article along with supplementary data files accessible online include all data generated during this study.

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