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A nursing care plan can present in two forms: informal and formal. Informal is a care plan for the individual use of the nurse and goals they wish to accomplish during their shift. Informal care plans are not included in the patient chart. A formal nursing care plan is a written or computerized guide that organizes patient care. It is further subdivided into two: standardized and individualized care plans. Standardized care plans are pre-populated care plans for specific patient populations,...
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Navigation Support during Transitions in Care for Persons with Complex Care Needs: A Systematic Review.

Lyndsay Howitt1, Greeshma Jacob1, Giulia Zucal1

  • 1Registered Nurses' Association of Ontario, 500-4211 Yonge Street, Toronto, ON M2P 2A9, Canada.

Healthcare (Basel, Switzerland)
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Summary

Patient navigation support during care transitions may improve follow-up visits and reduce readmissions for individuals with complex care needs. However, evidence quality is very low, necessitating further high-quality research.

Keywords:
care coordinationcontinuity of patient carehealthcare deliverysystem navigationtransitional care

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Area of Science:

  • Healthcare Management
  • Patient Care
  • Health Services Research

Background:

  • Individuals with complex care needs face elevated risks during care transitions.
  • These needs stem from chronic conditions, serious illness, or social vulnerability.
  • Adverse outcomes during transitions impact patient well-being and healthcare utilization.

Purpose of the Study:

  • To systematically review the impact of navigation support on patient outcomes during care transitions.
  • To inform the development of best practice guidelines for supporting complex patients.
  • To evaluate effects on quality of life, emergency visits, follow-up, satisfaction, and readmissions.

Main Methods:

  • Systematic review of 17 studies (2016-2023) across eight databases.
  • Included studies focused on transitions from hospital to home, with navigation support lasting 1-12 months.
  • Data were narratively synthesized, and evidence certainty was assessed using the GRADE approach.

Main Results:

  • Navigation support showed weak indications of increasing follow-up visits and patient satisfaction.
  • A potential reduction in 30-day readmissions was observed.
  • No significant differences were found in quality of life or 30-day emergency department visits.

Conclusions:

  • Patient navigation support during care transitions may offer benefits for individuals with complex needs.
  • Current evidence is limited by very low certainty, highlighting uncertainty in effectiveness.
  • High-quality research is essential to confirm the benefits and guide clinical practice.