Transitional Care Interventions in Improving Patient and Caregiver Outcomes After Discharge: A Scoping Review

Background. Caregivers play a fundamental role in the complexity of the transitional process between different healthcare settings. Current research shows that caregiver preparedness can affect the quality and efficacy of post-hospital care, therefore highlighting the need to integrate caregiver roles into the design of transitional care processes. This study aims to map existing evidence on effectiveness of transitional care interventions in improving post-discharge outcomes, as well as the influence of caregiver involvement on both patients and caregivers' outcomes. Methods. Referring to PRISMA-ScR guidelines, a systematic search was conducted between January and February 2024 on Scopus, WoS and PubMed. In order to be included in the systematic search, a study was required to use a RCT design, as well as to describe a transitional care intervention targeting caregivers or patient-caregiver dyads applied in the inpatient setting, lastly the study had to include follow-ups after discharge. There were no limitations on the country or publication year. Results. The review has included 51 RCTs of transitional care interventions, discussing caregivers' roles in improving dyad outcomes after discharge. Although the review highlighted a heterogeneity in the transitional care interventions, it was observed that the interventions shared some common components categorized in the following clusters: need assessments, providing information, psychological support, self-management training, and monitoring or follow-up. Conclusions. This review emphasizes the important role of caregivers in the transition from hospital to home, addressing a significant gap in the literature. It highlights the effectiveness of transitional care interventions in improving patients' quality of life and functional abilities while reducing caregivers' burden and depression. Further research should focus on assessing the efficacy of these interventions in relation to healthcare utilization, hospital readmission rates, and emergency department visits.