Table 3.

Characteristics of Included PICO-2 Care Transitions Outcome Studies

Author Location Year	No. Patients (Mean Age)	Inclusion Criteria	Exclusion Criteria	Study Design	Intervention Type	Patient Reported Measures	Caregiver Measures	Utilization Measures
Foulon33 Belgium 2019	100 (NR)	Health care providers involved directly in MM during CT; patient needed to be recently discharged from a hospital and familiar with health CT.	Prior involvement in pilot projects on continuity of MM.	Qualitative study using moderated focus group interviews analyzed with a thematic analysis approach. Topic guides for HCPs and patients were related to problems in the continuity of MM.	N/A	Participants identified the main problems in MM during CT, clustered into themes as such: 1) problems at admission, 2) problems at discharge 3) problems as to professions, 4) problems as to patients/families, and 5) problems as to process	No specific caregiver measures or outcomes were identified.	Timely follow-up with PCP.
Gettel34 US 2020	26 (83.0)	Aged ≥65 y, presenting to ED within 7 d of a fall, and likely to be discharged to community based on clinician judgement. English/Spanish-speaking.	Altered mental status, un-domiciled individuals, residents of a NH, or those with no follow-up phone numbers.	Qualitative study using grounded theory methodology nested within larger feasibility trial (GAPcare study). Patient, caregivers, or joint patient-caregiver dyads participated in interviews. Interview guide queried domains of ED care, symptom management after ED discharge, quality of in-ED and outpatient provider communication, views of the CT, perceptions of barriers to follow-up, and perceptions of clinical trajectories. cognitive impairment identified by <4 on SIS.	N/A	PLWD themes/quotes: feelings of being overwhelmed and often choose to not obtain recommended follow-up. Some patients noted loss of independence, fear of falling.	Caregiver themes/quotes: safety at SNFs greater than at home costs of LTC, making modifications to their lives after a fall-related ED visit. (cognitive impairment specific). There was also communication/coordination of care between providers, caregiver health metrics (sleep, psychological burden).	NR
Schnitker35 Australia 2015	580 (80.3)	Patients age ≥70 y presenting to the ED at 1 of 8 study hospitals between 2011 and 2012.	In the ED ≥2 h before recruitment by research RN, too ill to provide consent, had participated in this study previously during another ED visit, did not have an interpreter available within 2 h, or those who were not able to participate in planned 7 and 28-d follow-ups.	Phase 1: study first involved a systematic review of the literature to identify important care gaps and process Qls for patients with cognitive impairment. These measures were presented to an advisory panel of research, clinical, and consumer stakeholders to develop draft process measures. Phase 2: multicenter prospective and retrospective cohort study. Draft measures were field tested with older adults ≥70 y recruited during an ED visit between Sam and 5pm to evaluate initial quality of care. Phase 3: PQIs were then modified based on field testing and re-voted by panelists in 2 rounds to develop final set of PQI items.	22 QIs applied to older patients in the ED	A set of 11 PQIs for the evaluation of care processes relevant to older adult ED patients with cognitive impairment included: cognitive screening, delirium screening, delirium risk assessment, evaluation of acute change in mental status, delirium etiology, proxy notification, collateral history, involvement of a nominated support person, pain assessment, post-discharge follow-up, and ED LOS (proportion of older adults with ED stay >8 h). These were not necessarily patient-identified, but were formed by the group.	NR	Referrals for follow-up evaluation of cognitive status.

CT, care transition; HCP, health care provider; LOS, length of stay; LTC, long-term care; MM, medication management; N/A, not applicable; NH, nursing home; NR, not reported; PCP, primary care provider; PLWD, person living with dementia; PQI, process quality indicators; QI, qualitative indicators; RN, registered nurse; SIS, 6-item screener; SNF, skilled nursing facility.