Table 2.

Description and key features of the 20 TC innovations

TC innovation name	Target population	TC innovation—aims and key components	CFIR domains associated with the TC innovation’s implementation
Group I: 10 TC innovations to improve care transitionsb from hospital to home
APN-directed TCM: Advanced Practice Nurse-directed Transitional Care Model—Bradway et al. 2012, USA [31]	• ≥ 65 years older adults, hospitalized, cognitively impaired • Presence of a family caregiver (CG)	➢ Aims: to improve patient outcomes and ensure a safe and timely transition • Advanced practice nurse, role: ○ daily hospital visits to patient-CG dyad ○ home (or SNF) visitsa within 24 h post-discharge, a minimum of 4 ○ telephone follow-up and support ○ development of individualized care plans, patient-CG goals ○ implementation of risk reduction strategies to minimize effects of cognitive impairment ○ coordination with a multidisciplinary local team of healthcare experts ○ building CG ability to identify early symptoms and apply strategies to prevent poor outcomes	✓ Intervention characteristics ✓ Outer setting ✓ Characteristics of individuals ✓ Process
TCM Role: Transitional Care Manager Role—Couture et al. 2016, Canada [18]	• ≥ 70 years older adults, and/or chronically ill • Being discharged from hospital, or end of acute care is predictable	➢ Aims: to improve existing discharge planning practices • Transitional care manager (social worker, or any other healthcare professional, except nurses), a liaison agent role: ○ improvement of discharge planning by management of environmental and community barriers ○ exchange of patient information between providers ○ coordination of care and problem-solving of transitional care	✓ Intervention characteristics ✓ Inner setting
Community-based TCP: Community-based Transitional Care Program—Hung et al. 2015/2018, USA [32, 33]	• ≥ 65 years older adults • About to be discharged from hospital • At high risk of readmission	➢ Aims: to reduce preventable hospital readmissions and improve patient’s quality of life at home and in the community • Health coach (nurse or social worker), role: ○ home visits (within 24–48 h) post-discharge, follow-up phone calls and appointments with primary care providers • Discharge planning using “teach-back” methods • Connecting older adults to community services and resources • Support system network • Advanced care planning • Wellness coach up to 6 months	✓ Intervention characteristics ✓ Outer setting ✓ Inner setting ✓ Characteristics of individuals ✓ Process
CTI-Handoff: Care Transition Intervention Handoff—McNeil et al. 2016, Canada [34]	• Frail older adults with complex conditions • Discharged from hospital and require home care	➢ Aims: to reduce readmissions, improve information transfer, and enhance patient satisfaction • Patient care handoff between hospital care transition nurse and community rapid response nurse • Home care and follow-up period up to 30 days • Referral to hospital-based chronic disease management clinics	✓ Intervention characteristics ✓ Inner setting ✓ Characteristics of individuals ✓ Process
TCM: Transitional Care Model—Naylor et al. 2009, USA [35]	• Chronically ill, high-risk older adults • Hospitalized with multiple chronic conditions	➢ Aims: to improve patient outcomes, reduce readmissions, and reduce healthcare costs • Transitional care nurse, role: ○ primary care coordinator among providers and ensuring a multidisciplinary approach with open communication ○ in-hospital patient case assessment and development of care plan ○ regular home visits and ongoing telephone support (7 days/week over 2 months post-discharge) ○ continuity of medical care with hospital/primary care and accompanying patients on follow-up visits • Early identification and response to health risks • Active engagement of patients and their family/informal caregivers by focusing on education and support	✓ Intervention characteristics ✓ Outer setting ✓ Inner setting ✓ Characteristics of individuals ✓ Process
NUHS-RHS TCP: National University Health System-Regional Health Systems Transitional Care Program—Nurjono et al. 2019, Singapore [36]	• Older adults, and/or with complex healthcare needs • Frequent admitters to hospital • Have limited ambulation and caregivers at home	➢ Aims: to improve quality of care, reduce hospital utilizations, and reduce healthcare related costs • Care coordinator, an integrator role: ○ home visits, telephone monitoring ○ needs and home environment assessment ○ development of personalized care ○ promotion of self-care • Care coordination with a network of medical and social care providers in/out of hospital	✓ Intervention characteristics ✓ Outer setting ✓ Inner setting ✓ Characteristics of individuals ✓ Process
CTI: Care Transitions Intervention—Parrish et al. 2009, USA [37]	• Older adults, in hospital for chronic disease, and requiring long-term care	➢ Aims: to enhance patient safety during transitions • 4-week intervention • Transition coach (nurse or social worker), role: ○ hospital visit ○ 1 home visit (24–72 h post-discharge) ○ 3 follow-up phone calls • Improvement of patient’s capacity: ○ medication self-management ○ using a patient-centered health record ○ knowledge of “red flags” ○ making primary care provider/specialist appointments	✓ Inner setting ✓ Process
PaTH: Patient Trajectory for Home-dwelling elders—Rosstad et al. 2015, Norway [38]	• Elderly patients requiring home care services after discharge from the hospital	➢ Aims: to improve continuity of care and reduce the need of institutional care • Continuity of care from hospital and follow-up of home care recipients • Exchange of patient discharge information between the hospital, local healthcare allocations (municipality-level), and home care services: ○ local healthcare allocations office evaluate and decide on care assistance ○ home care service prepares for transition ○ home care nurse performs comprehensive patient assessment within 3 days upon discharge ○ general practitioner consults patient 14 days post-discharge ○ district nurse/nursing assistant performs extended assessment during the first 4 weeks • Communication among services through a patient daily care plan and patient checklist document	✓ Intervention characteristics ✓ Inner setting ✓ Characteristics of individuals ✓ Process
BOOST: Better Outcomes by Optimizing Safe Transitions—Williams et al. 2014, USA [39]	• Older adults • At high-risk of adverse events post-hospital discharge	➢ Aims: to improve patient’s discharge and reduce errors, reduce 30-day readmission rates, and improve patient satisfaction • Comprehensive intervention toolkit for clinical teams: ○ risk assessment ○ patient/caregiver education tools ○ teach back ○ discharge summary ○ follow-up phone call within 72 h • Implementation guide for multidisciplinary teams • Individual physician mentoring • BOOST collaborative across hospitals	✓ Intervention characteristics ✓ Inner setting ✓ Process
The Bridge Model—Xiang et al. 2018, USA [40]	• Older adults with complex care needs • Discharged from an inpatient hospital stay • At risk of readmission due to psychosocial determinants	➢ Aims: to improve care transition and prevent readmission by addressing the psychosocial determinants • Bridge care coordinator (social worker), role: ○ hospital visits ○ biopsychosocial needs assessment and development of a care plan ○ care coordination and follow-up in person or by telephone throughout 30 days post-discharge • Collaboration of hospital and community-based organizations for aging services	✓ Intervention characteristics ✓ Outer setting ✓ Inner setting ✓ Process
Group II: 4 TC innovations to improve care transitionsb from hospital to intermediary care places (residential care or rehabilitation facility) to a final destination
ICP Geri-Rehab: Integrated Care Pathway in Geriatric Rehabilitation for People with Complex Health Problems—Everink et al. 2017, the Netherlands [41]	• ≥ 65 years frail older adults with complex health problems • Previously admitted to hospital and geriatric rehabilitation care	➢ Aims: to improve communication between healthcare providers and enhance the triage process during transitions • Triage instrument for intermediary geriatric rehabilitation facility: ○ assessment of patient need for admission before movement to home setting • Care pathway coordinator, role: ○ communication between professionals and across settings ○ coordination and continuity of care • Active involvement of patients and informal caregivers • Patient discharge summaries • Evaluation meetings and open communication across providers	✓ Intervention characteristics ✓ Outer setting ✓ Inner setting ✓ Process
TC Places: Transition Care Places—Masters et al. 2008, Australia [42]	• Older adults • Concluded an acute hospital episode • Requiring more time and support in a non-acute setting to complete their restorative process and optimize their functional capacity	➢ Aims: to minimize inappropriate extended hospital length of stay, prevent inappropriate admission to residential aged care, and optimize patient’s independence/functional capacity • TC intermediary places located in a residential care facility or a community setting • Delivery of transition care in TC places: ○ goal-orientated, individualized ○ time-limited care ○ low-intensity therapies and services ○ case management • Finalization of long-term care arrangements	✓ Outer setting ✓ Inner setting ✓ Process
ICM: Intermediate Care Model—Plochg et al. 2005, the Netherlands [43]	• Frail older adults, chronically ill • Completed medical treatment at hospital but unfit to go home • Require long-term care	➢ Aims: to reduce length of hospital stays, prevent hospital readmissions, retain patient’s independence • Transfer unit (beds) located in a residential home: ○ low-intensity early discharge care model ○ provision of services bridging the acute, primary, and social care • Coordination of transitions by hospital liaison nurse	✓ Intervention characteristics ✓ Inner setting ✓ Characteristics of individuals ✓ Process
TC CAMP: Transition Care Cognitive Assessment and Management Pilot—Renehan et al. 2013, Australia [44]	• ≥ 65 years older adults • With cognitive impairment (dementia) • At conclusion of an episode of hospital care	➢ Aims: to reduce readmissions • TC CAMP intermediary restorative care places located in a residential care facility • Clinical nurse consultant (CNC), role: ○ case management ○ individualized care plan ○ behavioral management • “Key to Me,” patient information tool	✓ Intervention characteristics ✓ Inner setting ✓ Characteristics of individuals ✓ Process
Group III: 2 TC innovations to improve care transitionsb from hospital or home to nursing/residential care facility
QIP-TC: Quality Improvement Project to Improve Transitions of Care for Older People—Sutton et al. 2016, UK [45]	• Older people  • In transition between hospital and residential care settings during period of acute illness	➢ Aims: to improve communication and information transfer and reduce readmissions • Community geriatric service: ○ geriatrician and community nurse ○ 24-h telephone support and advisory service to facility staff • Patient information summary form	✓ Intervention characteristics ✓ Outer setting ✓ Characteristics of individuals ✓ Process
CPN: Follow-up visit by Community Psychiatric Nurse—Van Mierlo et al. 2015, the Netherlands [46]	• Older people with dementia behavioral disturbances • Expected to be admitted or are advised to move from home into a nursing facility	➢ Aims: to promote continuity of care and improve quality of care • Community psychiatric nurse (CPN), role: ○ follow-up visit 6 weeks after placement in a nursing home ○ clinical and behavioral assessment ○ support and advice to facility nurse ○ support to family caregiver	✓ Intervention characteristics ✓ Outer setting ✓ Inner setting ✓ Characteristics of individuals ✓ Process
Group IV: 4 TC innovations to prevent care transitionsc from nursing facility or home to hospital
HaH Plus program: Hospital at Home Plus Program—Brody et al. 2019, USA [14]	• ≥ 65 years older adults, requiring inpatient admission	➢ Aims: to reduce mortality, readmission rates, costs, and achieve better patient/caregiver satisfaction • Acute-level care services provision at home as a substitute for hospital admission, plus • A 30-day post-acute period of transitional care bundle (self-management, care coordination)	✓ Intervention characteristics ✓ Outer setting ✓ Inner setting ✓ Characteristics of individuals ✓ Process
OPTIMISTIC: Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care project—Ersek et al. 2018, USA [47]	• Frail older residents of nursing facility	➢ Aims: to reduce hospitalizations • OPTIMISTIC RNs’ and NPs’ role: ○ identification, assessment, and management of acute conditions in nursing home ○ promotion of INTERACT (Interventions to Reduce Acute Care Transfers) tools usage • Care activities organized within 3 care cores: medical, transitions, palliative	✓ Intervention characteristics ✓ Inner setting ✓ Characteristics of individuals ✓ Process
PCMH + TCM: Patient-Centered Medical Home + Transitional Care Model—Hirschman et al. 2017, USA [48]	• ≥ 65 years older adults with multiple chronic conditions • In community settings	➢ Aims: to prevent avoidable emergency room visits and hospitalizations, and provide a continuous care management • Patient-centered holistic approach • Combination of disease management in primary care settings and home care: ○ coordination of care during an episode of acute illness across settings, facilitated by: • Transitional care nurse (TCN), role: ○ home visits, telephone support ○ active engagement of patient, family caregivers, and collaboration with primary care providers ○ coordination of education and community services to develop self-management skills	✓ Outer setting ✓ Inner setting ✓ Characteristics of individuals ✓ Process
INTERACT II: Interventions to Reduce Acute Care Transfers—Rask et al. 2017, USA [49]	• Residents of long-term care settings	➢ Aims: to reduce the frequency of transfers to hospital, and improve quality of care for residents • Identification, evaluation, and communication of resident status changes • Use of 4 practice tools: ○ quality improvement ○ communication ○ decision support ○ advance care planning	✓ Outer setting ✓ Inner setting ✓ Characteristics of individuals ✓ Process

RNs registered nurses, NPs nurse practitioners

^aSometimes patients are admitted to (SNF) skilled nursing facility prior to going home; they receive visits in both settings

^b“Improve care transitions”—to provide and enhance the transitional care and services delivered during physical relocations of older persons from one care setting to another, with a view to creating optimal benefit as a result of the care transition

^c“Prevent care transitions”—to provide the care and services needed in order to avert an unnecessary or avoidable physical movement of older persons between two care settings or more