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Understanding transitional care programs for older adults who experience delayed discharge: a scoping review
Katherine S McGilton1,2, Shirin Vellani3,4, Alexandra Krassikova3,5
1KITE-Toronto Rehabilitation Institute, University Health Network, 550 University Avenue, Toronto, Ontario, Canada. kathy.mcgilton@uhn.ca.
BMC Geriatrics
|March 30, 2021
Summary
Transitional care programs (TCPs) help older adults with complex needs avoid delayed hospital discharge. These programs focus on assessment, care planning, and education, improving patient outcomes like functional status and enabling return home.
Area of Science:
- Gerontology
- Health Services Research
- Public Health
Background:
- Hospitalized older adults often face delayed discharge due to unmet post-acute care needs.
- Transitional care programs (TCPs) offer restorative care for older adults at risk of delayed discharge.
- Contextual factors influencing TCP implementation and outcomes require further investigation.
Purpose of the Study:
- To identify patient characteristics served by TCPs.
- To define the core components of TCPs.
- To examine reported outcomes of TCPs for older adults.
Main Methods:
- A six-step scoping review framework and PRISMA-ScR checklist were employed.
- Studies included TCP models evaluated in community-dwelling older adults (65+).
- Data synthesis utilized Donabedian's structure-process-outcome model.
Main Results:
- TCP patients were typically older women with multiple chronic conditions, cognitive impairment, and functional dependence.
- Core TCP components included assessment, care planning, treatment, discharge planning, and education.
- Key outcomes were functional status and discharge destination, with positive impacts noted.
Conclusions:
- TCPs can positively influence older adult outcomes, including successful return home.
- Effective TCPs involve interdisciplinary teams, proactive admission, cognitive impairment accommodation, and care partner involvement.
- Further research is needed on TCPs within integrated healthcare systems.
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