Table 3.
Intervention groupings
| Category | Description of intervention |
|---|---|
| Case management (n=8)23–27 43–45 | Based on implementation of a collaborative process between one or more care coordinators or case managers and the patient, to assess, plan and facilitate service delivery for patients with chronic diseases, particularly when transitions across healthcare settings are required |
| Chronic care model (n=9)28 29 46–51 69 | Model that identifies six modifiable elements of healthcare systems: (1) organisational support, addressing organisational culture and leadership, (2) clinical information systems to organise patient, population and provider data, (3) delivery system design to address composition and function of the care team and follow-up management, (4) decision support to increase provider access to evidence-based guidelines and specialists for collaboration, (5) self-management support to provide tailored education, skills training, psychosocial support and goal-setting and (6) community resources to provide peer support, care coordination and community-based interventions |
| Discharge management (n=15)30–36 52–59 | Interventions designed to facilitate effective transitions from hospital care to other settings. Typically includes a predischarge phase of support, transitional care for the move between the hospital and community/home setting and postdischarge follow-up and monitoring, often incorporating rehabilitation or reablement support |
| Complex interventions (n=3)60 61 70 | Two reviews assessed a range of interventions rather than focusing on a single intervention or service model |
| Multidisciplinary teams (n=10)37–40 62–66 71 | Interventions comprising teams composed of multiple health and/or social care professionals working together to provide care for people with complex needs. Teams typically included condition-specific expertise, nurses, occupational therapists, physiotherapists, social workers, GPs and occasionally pharmacists or case managers |
| Self-management (n=5)40–42 67 68 | Interventions designed to provide patient support, typically via tailored education to inform the patient about their condition(s), recognising signs and symptoms of disease exacerbation, dietary and lifestyle advice and/or condition-specific education supporting medication adherence |