This evidence theme on transition care is a summary of one of the key topics identified by a scoping review of rehabilitation, reablement, and restorative care research. If you need more information on this topic, try using the PubMed search below.
Overall, each review reported specific, yet different research aims with some similarities. Three reviews examined qualitative evidence to determine:
- the perspectives of patients with hip fractures using transition care [4]
- experiences of patients with dementia using transition care [5]
- how active involvement in care affected the experience of transition from one environment to another. [6]
Three reviews focused on the outcome measures used in transition care services [5, 7, 8] and a further three investigated interventions provided in transition care. [9-11] The remaining reviews examined:
- the extent to which community participation was considered in transition care services [1]
- the specific roles of rehabilitation professionals in transition care [10]
- the adaptation of the oldest old returning home following discharge from intensive care [12]
- the importance of discharge preparation and continuity of care. [13]
The reviews identified that:
- Experiences of transition care could be improved with better information provision to service users on what to expect when returning home, [1] an increased understanding of care provider roles, and a more organised discharge planning process. [4]
- Technologies such as video conferencing might be used to reduce barriers to care such as distance, allow planning and delivery of services, and improve communication and care between service providers. [4, 14]
- Transition care for older adults is an integral service that can reduce rehospitalisation rates. These services need to be delivered by professionals who plan, deliver, direct care, carry out regular assessments, and communicate effectively with older adults and family carers. [10, 13]
- Older adults discharged from intensive care units require individualised and continued care following discharge home to allow them to regain their independence and prevent rehospitalisation. [12]
- Barriers to accessing transition care include the readiness of healthcare services to deliver care, poor process planning, and older adults’ knowledge and uptake of supportive services. [9]
- Transition care services should support older adults to maintain the leisure and social activities they deem important. Continued participation can improve mobility, reduce falls, and increase community involvement and health-related quality of life. [1]
- Following the completion of transition care programs, it is unclear whether older adults regained their previous levels of mobility and independence. [7] Further evidence is required to determine whether continued support is required following the cessation of transition care packages.
- Transition care services commonly provided education and goal-orientated exercise and social support interventions addressing the older persons’ mobility, rehabilitation, and activities of daily living. Treatments focus on transfers, stair climbing, strength and balance exercises, and the provision of mobility aids. [8, 11]
- The implementation of transition care for older adults living with dementia is not well understood and raises clinical concerns for the focus of person-centred, individualised, high-quality care whilst long-term support is being arranged. [5]
