Table 1. Characteristics of Included Studies.

Source (country)	Design	Sample size	Brief intervention description	Who delivered the intervention	Focus of intervention	Involvement of primary care or community clinician	Time point of intervention	Direction of transfer
Cordato et al,48 2018 (Australia)	Prospective RCT	45	Regular Early Assessment Post-Discharge intervention. Conjoint geriatrician and nurse practitioner evaluations (involving cognition, medication use, and quality of life) for 6 mo after discharge.	Geriatrician and nurse practitioner	Resident focused	REAP clinicians advise GPs on investigations and treatments.	After discharge	Hospital to LTCF
Crilly et al,49 2011 (Australia)	Nonrandomized clincial trial	177	HINH program involving acute nursing support, provision of equipment, training and education for staff, regular checks on patient progress by an HINH nurse.	Aged care facility nursing staff; HINH nurse	Mix: staff and system focused	None	At admission	Hospital to LTCF
Crotty et al,50 2004 (Australia)	RCT	110	Pharmacist transition coordinator coordinated medication transfer summaries from hospital, medication reviews, case conferences with physicians and pharmacists.	Pharmacist	System focused	Family physicians and community pharmacists sent extra information.	Multiple: before and after discharge	Hospital to LTCF
Crotty et al,51 2005 (Australia)	RCT	320	Off-site care facility for patients awaiting assessment and transfer to a care home.	Hospital and private care clinician	System focused.	None	Multiple: after discharge and during transition	Hospital to LTCF
Elliott et al,52 2012 (Australia)	Prospective preintervention-postintervention study	593	Pharmacist-prepared IRCMAC sent with the patient from the hospital to the care facility.	Hospital pharmacist	System focused	None	Multiple: after discharge and during transition	Hospital to LTCF
Harvey et al,53 2014 (Australia)	RCT	123	Outreach service: assessment and development of care plan, advance care plan discussions with patients and families, intercurrent illness management reviews, education and support for care facility staff and primary care physician.	Geriatrician and aged care nurse consultant	Mix: resident and staff focused	Primary care physician received education and support	After discharge	Hospital to LTCF
Hullick et al,31 2016 (Australia)	Controlled preintervention-postintervention design	413	Aged Care Emergency Service: clinical care manual, nurse-led telephone triage line, education, case management, development of collaborative relationships.	ED advanced practice nurse; ED registered nurse	System focused	None	Before admission	LTCF to hospital
Kane et al,57 2017 (US)	Cluster RCT (implementation trial)	23 478	Tools to identify changes in patients, document staff communication, care paths, project champions. Training, telephone support and webinars for staff (to support implementation of INTERACT).	Study team and nursing home staff	Mix: staff and system focused	None	Before admission	LTCF to hospital
Layton,58 2019 (US)	Quasi-experimental, 2-group design	38	CHF-specific education and protocols for nursing home staff: education on documentation, care plan implementation, assessment and skills.	Educational intervention delivered to frontline nursing home staff (eg, registered nurses, nursing assistants)	Staff focused	None	Intervention for staff was before admission, relevant to patients after discharge	LTCF to hospital
Lee et al,60 2002 (Hong Kong)	Matched, randomized case-control trial	89	Postdischarge care protocol, education for nursing home staff, information sharing with patients and staff, individualized care planning, telephone support.	Delivered by community nursing staff to nursing home staff and patients	Mix: staff and resident focused	Community nurses provided support to nursing home staff.	Begins after initial discharge and can be before and after subsequent readmissions	Hospital to LTCF
Mudge et al,56 2012 (Australia)	Controlled trial	1004	Model of care involving greater and consistent staffing, structured daily interdisciplinary meetings, explicit discharge planning.	Clinical staff based at the hospital	System-focused model of care	None	Before discharge	Hospital to LTCF
Mukamel et al,59 2016 (US)	RCT	225	Reengineered discharge process and app to support patient selection of nursing home. App included an educational module and a preference elicitation module.	Project coordinator provided iPad; intervention delivered via app	Resident focused	None	Before discharge	Hospital to LTCF
Pedersen et al,61 2018 (Denmark)	Quasi-randomized study	648	Individualized postdischarge support: assessment of clinical condition, medication, discussions with the patient, relatives, and nursing home staff. In-person and telephone support.	Physician and nurse from a geriatric team	Resident focused	None	After discharge only	Hospital to LTCF
Shrapnel et al,54 2019 (Australia)	Preintervention-postintervention study	1130	HINH-inspired model of care. Clinical liaison with care facility staff and GP clinicians, acute care management, shared accountability for care.	Specialist nurse	Mix	Hospital-based nurses worked in partnership with GP clinicians.	Before admission, at admission, before discharge	Both LTCF to hospital and hospital to LTCF
Street et al,55 2015 (Australia)	Preintervention-postintervention study	4329	Residential In-Reach service: skilled assessment and diagnostic support to care facility staff, telephone advice and triage, in-person support, education, and training for staff.	Specialist practice nurses, supported by a geriatrician	Mix	None	Before admission	LTCF to hospital

Abbreviations: app, application; CHF, congestive heart failure; ED, emergency department; GP, general practitioner; HINH, Hospital in the Nursing Home; INTERACT, Interventions to Reduce Acute Care Transfers; IRCMAC, interim residential care medication administration chart; LTCF, long-term care facility; RCT, randomized controlled trial.