Table A2: Randomized Controlled Trials.

Author, Year, Size	Intervention	Patient Population	Outcomes	EPOC Risk of Bias	Limitations/Comments
Balaban et al, 2008 (12) N = 96	A comprehensive patient discharge form was given to patients to identify any communication problems during transition of care (i.e., lack of knowledge about condition and gaps in outpatient follow-up care or test results). Discharge form electronically transferred to the RN at patients’ primary care facility. RN contacted patient and reviewed form and medication included in the discharge plan. RN phoned patient to assess status, review form, assess patient concerns and confirm follow-up appointments. Form and telephone notes forwarded electronically to PCP who reviewed the form.	Patients admitted to a 100-bed community teaching hospital as an emergency Patients with diabetes, HF, COPD, depression	Hospital LOS and readmission rates Follow-up at 21 and 31 days	Adequate sequence generation? Unclear Allocation concealment? Unclear Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? No	122 randomized 24 excluded after randomization because discharged to another institution; 2 died during hospital admission
Bolas et al, 2004 (28) N = 243	Use of a comprehensive medication history service, provision of an intensive clinical pharmacy service including management of patients’ own drugs brought to hospital, personalized drug record and patient counselling to explain changes at discharge. Discharge letter outlining complete drug history on admission and explanation of changes to medication during hospital and variances to discharge prescription faxed to GP and community pharmacist. Personalized drug card, counselling, labelling of dispensed drugs for follow-up. Drug helpline. Control intervention: standard clinical pharmacy services.	Patients admitted to district general hospital Aged ≥ 55 years and taking ≥ 3 regular drugs	Patient satisfaction Knowledge of drugs Hoarding of drugs	Adequate sequence generation? Yes Allocation concealment? Unclear Blinding? No Incomplete outcome data addressed? No Free of selective reporting? Unclear Baseline data? Yes	Follow-up of patients: 67% (162/243) Low response rate in survey of GPs (55%) and community pharmacists (56%) Unclear how standard clinical pharmacy services differ from intervention.
Evans et al, 1993 (17) N = 835	Patients screened for risk factors that may prolong hospital LOS, increase risk of readmission, or discharge to a nursing home. During discharge planning, information on support systems, living situation, finances, and areas of need were obtained from medical notes, interviews with the patient and family, and by consulting with the physician and nurse. Discharge planning initiated on day 3 of hospital admission, with patients referred to a social worker. Plans implemented with measureable goals using goal attainment scaling. Control intervention: discharge planning only if referred by medical staff and usually on the 9th day of hospital admission, or not at all.	Patients screened for risk factors that would prolong their LOS at a VA hospital Older patients with a medical condition, neurological condition, or recovering from surgery	Hospital LOS Readmission to hospital Discharge destination Health status Follow-up at 3 months	Adequate sequence generation? Unclear Allocation concealment? Unclear Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes	Controls could receive discharge planning
Harrison et al, 2002 (29) N = 200	Patients’ notes were flagged at admission as a signal to the primary nurse to follow a checklist for discharge planning. Hospital and community nurses working together for a smooth transition from hospital to home. A structured protocol was used for counselling and education for HF self-management. Home nursing visits were the same number as the control group. Telephone outreach within 24 hours of discharge. Control intervention: usual care for hospital to home transfer that involved completing a medical history, nursing assessment form, and a multidisciplinary plan. Discharge planning meetings took place weekly. Regional home care co-ordinator consulted with the hospital team as needed. Patients received the same number of home nurse visits as the intervention group.	Older, cognitively unimpaired people with HF who were expected to be discharged (from a large urban teaching hospital) with home nursing care	HRQOL Symptoms distress and functioning ED visits and readmissions at 12 weeks	Adequate sequence generation? Yes Allocation concealment? Unclear Blinding? Yes Incomplete outcome data addressed? No Free of selective reporting? Yes Baseline data? Yes
Hendriksen et al, 1990 (30) N = 273	Patients had daily contact with the project nurse who discussed their illness and discharge arrangements with them. Liaison between hospital and primary care staff. Project nurse visited patients at home after discharge and could make one repeat visit. Control intervention: described as “usual care.”	Elderly patients admitted to a suburban hospital	Hospital LOS Readmission to hospital Discharge destination	Adequate sequence generation? Unclear Allocation concealment? Unclear Blinding? Yes Incomplete outcome data addressed? Unclear Free of selective reporting? Unclear Baseline data? Yes	Details of measures of outcome not provided Translated from Danish
Jack et al, 2009 (20) N = 749	At admission, the nurse discharge advocate completed the discharge intervention components. With information collected from the hospital team and patient, the discharge advocate created the after-hospital care plan that contained medical provider contact information, dates for appointments and tests, an appointment calendar, a colour-coded drug schedule, a list of tests with pending results at discharge, an illustrated description of the discharge diagnosis, and information about what to do if a problem arises. Information for the after-hospital care plan was manually entered into a Microsoft Word template, printed, and bound to produce an individualized booklet. Discharge advocate used scripts from the training manual to review contents of the after-hospital care plan with the patients. On day of discharge, the plan and discharge summary were faxed to the PCP. Pharmacist telephoned patients 2–4 days after the index discharge to reinforce the discharge plan by using a scripted interview. Pharmacist had access to the care plan and discharge summary and over several days made at least 3 attempts to reach each patient. Pharmacist asked patient to bring drugs to the phone, review them, and address any problems. Pharmacist communicated these issues to the PCP or discharge advocate.	Patients who were emergency admissions to the medical teaching service and who were going to be discharged home	Readmission Patient satisfaction	Adequate sequence generation? Yes Allocation concealment? Yes Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes
Kennedy et al, 1987 (31) N = 80	Discharge planning emphasized communication with the patient and family. A primary nurse assessed patients’ postdischarge needs. A comprehensive discharge planning protocol was developed that included an assessment of health status, orientation level, knowledge and perception of health status, pattern of resource use, functional status, skill level, motivation, and sociodemographic data. Implementation of the discharge plan by the primary nurse and other members of the health care team. Follow-up visit made to assess discharge placement. Control intervention: not described.	Elderly acute care medical patients in a non-profit teaching hospital	Hospital LOS Readmission to hospital Discharge destination Health status	Adequate sequence generation? Yes Allocation concealment? Yes Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes	Not clear when intervention implemented
Laramee et al, 2003 (32) N = 287	Early discharge planning and co-ordination of care and individualized and comprehensive patient and family education. Case manager assisted in the co-ordination of care by facilitating the discharge plan and obtaining needed consultations from social services, dietary services, and physical/occupation therapy. If needed, arrangements were made for additional services or support once the patient had returned home. Case manager also facilitated communication in the hospital among patient and family, attending physician, cardiology team, and other practitioners by participating in daily rounds, documenting patient needs in the medical record, submitting progress reports to the primary care physician, involving the patient and family in developing the plan of care, collaborating with the home health agencies, and providing informational and emotional support to the patient and family. 12 weeks of enhanced telephone follow-up and surveillance. Control intervention: social services evaluation (25% for usual care group), dietary consultation (15% usual care), physiotherapy/occupational therapy (17% usual care), drug and HF education by staff nurses and any other hospital services. Home care (44%).	Patients admitted to an academic medical centre with confirmed HF who were at risk for early readmission	Readmissions Mortality Hospital bed days Resource use Patient satisfaction Follow-up at 3 months	Adequate sequence generation? Unclear Allocation concealment? Unclear Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes
Moher et al, 1992 (33) N = 267	A nurse employed as a team co-ordinator acted as a liaison between members of the medical team and collected patient information. The nurse facilitated discharge planning. Control intervention: standard medical care.	Elderly medical patients admitted to a teaching hospital	Hospital LOS Readmission to hospital Discharge destination Patient satisfaction	Adequate sequence generation? Yes Allocation concealment? Unclear Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes	Baseline data recorded only on age, sex, diagnosis Not clear when intervention implemented
Naji et al, 1999 (34) N = 343	Psychiatrist telephoned GP to discuss patient and make an appointment for the patient to see the GP within 1 week following discharge. A copy of the discharge summary was given to the patient to hand deliver to the GP. Control intervention: standard care. Patients advised to make an appointment to see their GP and were given a copy of the discharge summary to hand deliver to the GP.	Acute psychiatric admissions	Readmission Mental health status Discharge process Follow-up at 1 month for patient assessed outcomes 6 months for readmissions	Adequate sequence generation? Yes Allocation concealment? Yes Blinding? Yes Incomplete outcome data addressed? Unclear Free of selective reporting? Unclear Baseline data? Yes	Psychiatric patients
Naughton et al, 1994 (35) N = 111	A geriatric evaluation and management team assessed the patient’s mental and physical health status and psychosocial condition to determine level of rehabilitation required and social needs. A geriatrician and social worker were the core team members. Team meetings with the team and nurse specialist and physical therapist took place twice a week to discuss patients’ medical condition, living situation, family and social supports and patient and family’s understanding of the patient’s condition. Social worker responsible for identifying and co-ordinating community resources and ensuring the posthospital treatment place was in place at the time of discharge and 2 weeks later. Nurse specialist co-ordinated the transfer to home health care. Patients who did not have a primary care provider received outpatient care at the hospital. Control intervention: received “usual care” by medical house staff and an attending physician. Social workers and discharge planners were available on request.	Elderly medical patients admitted from ED in a non-profit academic medical centre	Hospital LOS Discharge destination	Adequate sequence generation? Yes Allocation concealment? Yes Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes	Intervention implemented at time of admission
Naylor et al, 1994 (24) N = 276	Discharge plan included a comprehensive assessment of the needs of the elderly patient and their caregiver, an education component for the patient and family, and interdisciplinary communication regarding discharge status. Implemented by geriatric nurse specialist and extended from admission to 2 weeks postdischarge with ongoing evaluation of the effectiveness of the discharge plan. Control intervention: routine discharge planning available in the hospital.	Elderly medical and cardiac surgery patients in an academic medical centre	Hospital LOS Readmission to hospital Health status	Adequate sequence generation? Unclear Allocation concealment? Unclear Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes	Intervention implemented at time of admission
Nazareth et al, 2001 (36) N = 362	Hospital pharmacist assessed and rationalized the patients’ drug treatment, provided information, and liaised with caregiver and community professionals. Aim was to optimize communication between secondary and primary care professionals. Follow-up visit by community hospital 7–14 days after discharge to check drug and intervene if necessary. Subsequent visits arranged if appropriate. Copy of discharge plan given to the patient, caregiver, community pharmacist, and GP. Follow-up in the community by a pharmacist. Control intervention: discharge from hospital following standard procedures, which included a letter of discharge to the GP. Pharmacist did not provide a review of drugs or follow-up in the community.	Elderly patients on ≥ 4 drugs who were discharged from 3 acute wards and 1 long-stay ward	Hospital readmission Mortality HRQOL Client satisfaction Knowledge and adherence to prescribed drugs Consultation with GP	Adequate sequence generation? Yes Allocation concealment? Yes Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes
Pardessus et al, 2002 (37) N = 60	All admitted patients during the trial period were screened for inclusion and exclusion criteria. 2-hour home visit by occupational therapist and a physical medicine/rehabilitation doctor to evaluate patient abilities in home environment. Enabled observation of patient in their living conditions.. Social supports addressed by social worker. Modification of home hazards and safety advice in home situation, adaptation of recommendations and prescriptions particularly for physical therapy, speedy evaluation of necessary technical aids and social supports. Telephone follow-up was conducted by an occupational therapist to check if the home modifications were completed and assist if necessary. Control intervention: received physical therapy and were informed of home safety and social assistance if required. No home visit.	Patients aged ≥ 65 years who were hospitalized due to falls and able to return home	Functional status Falls Readmissions Mortality Residential care at 6 and 12 months	Adequate sequence generation? Yes Allocation concealment? Unclear Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Unclear
Parfrey et al, 1994 (38) N = 841	Developed a questionnaire to identify patients requiring discharge planning. Assessment based on the questionnaire that covered the patient’s social circumstances at home, if the admission was an emergency admission or a readmission, use of allied health and community services, mobility and activities of daily living, and medical or surgical condition. Referrals to allied health professionals following completion of the questionnaire for discharge planning. Control intervention: did not receive the questionnaire. Discharge planning occurred if the discharge planning nurses identified a patient or received a referral.	Medical and surgical patients	Hospital LOS at 6 and 12 months	Adequate sequence generation? Unclear Allocation concealment? Yes Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes	Intervention implemented at time of admission
Preen et al, 2005 (39) N = 189	Discharge planning was based on the Australian Enhanced Primary Care Program and tailored to each patient. Discharge plan was developed 24–48 hours prior to discharge. Problems were identified from hospital notes and patient/caregiver consultation, goals were developed and agreed upon with the patient/caregiver based on personal circumstances and interventions, and community service providers who met patient needs and who were accessible and agreeable to the patient were identified. Discharge plan was faxed to the GP and consultation with the GP was scheduled within 7 days postdischarge. Copies faxed to all service providers identified on the care plan. Research nurse followed up if GP did not respond in 24 hours and the GP scheduled a consultation (within 7 days postdischarge) for patient review. Control intervention: patients were discharged under the hospitals’ existing processes following standard practice in Western Australia where all patients have a discharge summary completed, which was copied to their general practitioner.	Patients with COPD, cardiovascular disease, or both in 2 tertiary hospitals	SF-12 Patient satisfaction and views of discharge process and GP views of the discharge planning process at 7 days postdischarge	Adequate sequence generation? Unclear Allocation concealment? Yes Blinding? No Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes
Rich et al, 1993 (40) N = 98	Intensive education about HF and its treatment during daily visits by cardiovascular research nurse to discuss diagnosis, symptoms, treatment, follow-up, and prognosis using a 15-page booklet. Dietary advice by dietician and study nurse. Assessment of medication with recommendations designed to improve compliance and reduce adverse effects. Drug card provided detailing the time, dose, and side effects of all drugs. Daily recording of weights emphasized and patients instructed to contact researchers for weight changes in excess of 3 to 5 pounds. Scales provided if needed. Early discharge planning. Patient seen by social worker and member of the home care team to facilitate discharge planning and ease the transition from the hospital to home. Economic, social, and transport problems identified and managed. Enhanced follow-up through home care and telephone contacts with additional assistance provided if needed. Patients visited at home within 48 hours of discharge and then 3 times in the first week and at regular intervals thereafter. At each visit, home care nurse reinforced the teaching materials, reviewed medications, diet and activity guidelines, physical assessment and cardiovascular examination plus assessed for additional problem areas. Study nurse contacted patients by phone and patients were encouraged to call researchers or personal physician with any new problems or questions. Control intervention: all conventional treatments as requested by the patient’s attending physician. These included social service evaluation, dietary and medical teaching, home care, and all other available hospital services. Received study education materials and formal assessment of drugs.	Older people with HF in an academic medical centre	Hospital LOS Readmission to hospital Readmission days HRQOL	Adequate sequence generation? Yes Allocation concealment? Unclear Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes
Rich et al, 1995 (41) N = 282	Inpatient assessment included using a teaching booklet, individualized dietary assessment and instruction by dietician with reinforcement by the cardiovascular research nurse, consultation with social services, assessment of drugs by geriatric cardiologist, intensive follow-up after discharge through the hospital’s home care services plus individualized home visits and telephone contact with the study team. Control intervention: received all standard treatment and services ordered by their primary physicians.	Admitted to an academic medical centre with confirmed HF and at least one risk factor for readmission	Mortality Readmission to hospital HRQOL	Adequate sequence generation? Yes Allocation concealment? Yes Blinding? Yes Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes	HRQOL data were collected from a subgroup of patients only (n = 126).
Shaw et al, 2000 (42) N = 97	Predischarge assessment with a pharmacy checklist that assessed patients’ knowledge and identified particular problems such as therapeutic drug monitoring, compliance aid requirements, and side effects. Pharmacy discharge plan supplied to the patients’ community pharmacist for the intervention group. Control intervention: not described.	Patients discharged from a psychiatric hospital or care of the elderly ward	Readmission to hospital Readmission due to noncompliance Drug problems after discharge	Adequate sequence generation? Yes Allocation concealment? Yes Blinding? No Incomplete outcome data addressed? Unclear Free of selective reporting? Unclear Baseline data? Yes	Psychiatric patients
Sulch et al, 2000 (43) N = ?	Rehabilitation and discharge planning with regular review of discharge plan. Senior nurse implemented and integrated care pathway. Multidisciplinary training preceded implementation of the pathway. Pathway piloted for 3 months prior to recruitment to the trial. Control intervention: to avoid contamination, the multidisciplinary process of care received by the control group was reviewed with a 3-month run-in period to ensure implementation. Both groups received comparable amounts of physiotherapy and occupational therapy.	Patients recovering from stroke in a stroke rehabilitation unit at a teaching hospital	Hospital LOS Discharge destination Mortality at 26 weeks Mortality or institutionalization Activities of daily living HRQOL	Adequate sequence generation? Yes Allocation concealment? Yes Blinding? No Incomplete outcome data addressed? Yes Free of selective reporting? Unclear Baseline data? Yes
Weinberger et al, 1996 (44) N = 1,396	3 days before discharge a primary nurse assessed the patient’s postdischarge needs. 2 days before discharge the primary care physician visited the patient and discussed patient’s discharge plan with the hospital physician and reviewed the patient. Primary nurse made an appointment for the patient to visit the primary care clinic within 1 week of discharge. Patient given educational materials and a card with the names and beeper numbers of the primary care nurse and physician. Primary care nurse telephoned the patient within 2 working days of discharge Primary care physician and primary nurse reviewed and updated the treatment plan at the first postdischarge appointment. Control intervention: did not have access to the primary care nurse and received no supplementary education or assessment of needs beyond usual care.	Multicentre patients with diabetes, HF, and COPD.	Readmission to hospital Health status Patient satisfaction Intensity of primary care		Discharge planning within 3 days of discharge 9 Veterans Administration hospitals participated in the trial

Abbreviations: COPD, Chronic Obstructive Pulmonary Disease; ED, emergency department; EPOC, Effective Practice and Organization of Care Group; HF, heart failure; HRQOL, health-related quality of life; LOS, length of stay; PCP, primary care provider; RN, registered nurse.

Source: Shepperd et al, 2009. (4).