Care Transition Strategies, Opportunities, and Challenges for Patients Following COVID-19 Hospitalization: An...

Area of Science:

• Healthcare Management
• Public Health
• Health Services Research

Background:

• Fragmentation of healthcare services poses challenges to continuity of care.
• Effective care transition strategies are crucial for patients post-hospitalization, particularly for COVID-19 survivors.

Purpose of the Study:

• To review scientific evidence on care transition strategies for COVID-19 patients after hospitalization.
• To identify implementation opportunities and challenges for these strategies.

Main Methods:

• Integrative literature review adhering to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.
• Searched multiple databases (MEDLINE, Web of Science, EMBASE, CINAHL, LILACS, Cochrane, SciELO, Scopus) for articles published 2020-2023.
• Included 14 articles, analyzing themes related to virtual care, patient/professional experiences, post-discharge needs, and assessment tools (CTM-15).

Main Results:

• Care transition strategies like teleconsultations, videoconferencing, and telerehabilitation can decrease complications and readmissions, enhancing patient satisfaction.
• Key challenges include early discharge, communication gaps, inconsistent protocols, and care discontinuity.
• Patient-centered planning, telehealth integration, and systematic assessment tools (e.g., CTM-15) are vital for optimizing post-hospital care.

Conclusions:

• Structured, patient-centered care transition planning is essential for COVID-19 survivors.
• Integrating telehealth and remote monitoring offers significant opportunities to improve post-hospital care.
• Addressing identified challenges is critical for ensuring seamless and effective care transitions.