Table 1.

Characteristics of included papers

Study	Country	Study type/design	Setting	Patient population	Sites	Chronic care condition	Type of hospital avoidance programme	Outcomes assessed
Acton et al. [50]	USA	Quantitative—RCT pilot	Hospital	Adult in-patients with type 1 or 2 DM, with home experience of using basal-bolus insulin	1	DM	Self-managed insulin	Length of stay
Axon et al. [51]	USA	Mixed methods	Various: hospital, home, hospices	CHF, COPD, pneumonia, AMI patients	68	CHF + COPD	1. Risk assessment 2. Education (teach back) 3. Follow-up (phone calls and appointments) 4. Transition (records, coaching), discharge summaries 5. Multidisciplinary rounds	Hospital readmissions
Benzo et al. [52]	USA	Qualitative	Hospital	Inpatient admitted with acute exacerbation of COPD	1	COPD	Pulmonary rehabilitation and exercise	Hospital readmissions
Fisher et al. [53]	USA	Qualitative	Hospital	Patients with severe exacerbations of COPD	7	COPD	Non-invasive ventilation	Length of stay
Hopkinson et al. [54]	UK	Mixed methods	Hospital	Inpatients admitted with acute exacerbation of COPD	1	COPD	1. Discharge care bundle 2. Post discharge follow-up phone call	Hospital readmissions
Lennox et al. [47]	UK	Qualitative	Hospital	Inpatients admitted with acute exacerbation of COPD	7	COPD	Care bundle	Hospital readmissions Length of stay
Morton et al. [55]	UK	Mixed methods	Hospital	Admitted patients with acute exacerbation of COPD	31	COPD	Admission and discharge care bundles	Hospital readmissions
Nguyen et al. [56]	Canada	Mixed methods	Hospital	HF patients (> 65) attending the general hospital Heart Function Clinic	1	CHF	Technology-based decision support to support self-care in older HF patients and their care partners	Hospital readmissions
Seys et al. [57]	Belgium, Italy, and Portugal	Quantitative	Hospital	Inpatients admitted with acute exacerbation of COPD	19	COPD	Care pathway	Hospital readmissions
Willemse et al. [58]	Belgium	Qualitative	Primary and secondary care	Community-based CHF patients	7	CHF	Telemonitoring and self-management	Hospital readmissions
Wood et al. [59] Study 1	USA	Quantitative	Hospital	Inpatients admitted with first diagnosis of HF in a military healthcare facility	1	CHF	Practice changes 1. Education tool which included instructions on medications, daily weights, exercise, sodium intake, reporting symptoms, recording follow-up appointments. 2. Making a patient follow-up appointment in HF facility within 10 days	Hospital readmissions
Wood et al. [59] Study 2	USA	Quantitative	Hospital	Patients with a history of HF discharged to participating SNFs in a civilian healthcare facility	1	CHF	Handoff protocol established to aid in the transition of care from inpatient to outpatient setting	Hospital readmissions
Wright et al. [60]	New Zealand	Quantitative–RCT	Hospital	Admitted with first diagnosis or an exacerbation of pre-existing HF	1	CHF	Self-management	Hospital readmissions
Yeager et al. [61]	USA	Qualitative	Hospitals and health centres	> 65 years diagnosed with DM plus one other chronic condition and Medicare eligible	6	DM	Care coordination model	Hospital admissions Emergency department presentations

DM diabetes mellitus, CHF congestive heart failure, HF heart failure, AMI acute myocardial infarction, COPD chronic obstructive pulmonary disease, SNF skilled nursing facility, RCT randomised controlled trial