Transitional rehabilitation care and patient care continuity as an advanced nursing practice

Pedrosa, Ana Rita Cardoso; Ferreira, Óscar Ramos; Baixinho, Cristina Rosa Soares Lavareda

doi:10.1590/0034-7167-2021-0399

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Revista Brasileira de Enfermagem

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Sumário

REVIEW • Rev. Bras. Enferm. 75 (05) • 2022 • https://doi.org/10.1590/0034-7167-2021-0399 copy

Transitional rehabilitation care and patient care continuity as an advanced nursing practice

Cuidado transicional de rehabilitación y continuidad de atención al paciente como práctica avanzada de enfermería

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To analyze the needs and facilitating and hindering elements related to transitional rehabilitation care.

Methods:

Integrative literature review oriented toward answering the question “What nursing interventions guarantee transitional rehabilitation care to dependent adult or elderly people when they return home after hospitalization?”.

Results:

The patients did not participate much in the planning of hospital discharge and decision-making when they had to return home. Informal caretakers reported that professionals showed detachment during hospitalization and delayed guiding instructions. Health professionals mentioned lack of time to offer this care modality as a difficulty.

Final considerations:

Ensuring training, follow-up, and coordination between care levels is essential. Care integration can reduce hospital stay and the impact of post-discharge complications. Transitional care contributes to a sustainable health system, higher care quality, and client satisfaction.

Descriptors:
Transitional Care; Continuity of Patient Care; Advanced Practice Nursing; Hospitalization; Patient Discharge

Reference	Country/Year	Study type Sample	Objectives	Outcomes
S1(⁹9 Dyrstad DN, Testad I, Aase K, Storm M. A review of the literature on patient participation in transitions of the elderly. Cognit Tech Work. 2015;17(1):15-34. https://doi.org/10.1007/s10111-014-0300-4 https://doi.org/10.1007/s10111-014-0300-... )	Norway 2015	Literature review n=30 articles	Offering an overview of the studies, which addressed the participation of elderly people in transitional care.	The level of participation of elderly people in the planning of hospital discharge and decision-making was low, although people wanted to be included in these processes. The authors recommended considering the implementation of tools to support patient participation to improve transitional care of elderly people.
S2(¹⁰10 Wong FK, Yeung SM. Effects of a 4-week transitional care programme for discharged stroke survivors in Hong Kong: a randomised controlled trial. Health Soc Care Community. 2015;23(6):619-31. https://doi.org/10.1111/hsc.12177 https://doi.org/10.1111/hsc.12177... )	China 2015	Randomized clinical trial n=108 participants	Testing the effectiveness of a transitional care program developed over four weeks and carried out by a nurse.	The intervention group showed better spiritual, religious, and personal results, greater satisfaction, higher scores in the modified Barthel index, lower depression scores, and lower hospital readmission and urgency service admission rates compared to the control group.
S3(¹¹11 Jackson C, Shahsahebi M, Wedlake T, DuBard CA. Timeliness of outpatient follow-up: an evidence-based approach for planning after hospital discharge. Ann Fam Med. 2015;13(2):115-22. https://doi.org/10.1370/afm.1753 https://doi.org/10.1370/afm.1753... )	United States 2015	Longitudinal observational quantitative study n=44,473 participants	Testing whether the risk of readmission was associated with the probability of receiving the benefit of early follow-up at home.	Follow-up within 14 days after discharge was associated with a reduction of 1.5% and 19.1% in readmission rate in lower risk strata and higher risk strata, respectively. Follow-up within seven days after discharge was associated with a reduction of more than 20% in the chances of readmission in people with multiple chronic pathologies.
S4(¹²12 Allen J, Hutchinson AM, Brown R, Livingston PM. User experience and care for older people transitioning from hospital to home: Patients' and carers' perspectives. Health Expect. 2018;21(2):518-527. https://doi.org/10.1111/hex.12646 https://doi.org/10.1111/hex.12646... )	Australia 2017	Qualitative study n=26 participants	Describing the experience of patients and caretakers in the transition from hospital to community.	All participants reported the need to become independent over the transition. They realized that a number of social processes helped them get their independence at home: supporting relationships with caretakers and health professionals, search for information, discussion of and negotiation on the transitional care plan, and learning of self-care.
S5(¹³13 Langhorne P, Baylan S; Early Supported Discharge Trialists. Early supported discharge services for people with acute stroke. Cochrane Database Syst Rev. 2017;17(7):CD000443. https://doi.org/10.1002/14651858 https://doi.org/10.1002/14651858... )	United Kingdom 2017	Systematic literature review n=17 articles	Comparing conventional care offered to people who had cerebrovascular accident and programs with early hospital discharge and rehabilitation carried out in the community.	The services with a policy of early discharge, adequate resources, and contribution of a coordinated multidisciplinary team offered to a selected group of people who had cerebrovascular accident reduced their long-term dependence, rate of admission to care institutions, and hospital stay.
S6(¹⁴14 Sahota O, Pulikottil-Jacob R, Marshall F, et al. The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency. Age Ageing. 2017;46(1):26-32. https://doi.org/10.1093/ageing/afw149 https://doi.org/10.1093/ageing/afw149... )	United Kingdom 2017	Randomized clinical trial n=250 participants	Comparing the clinical effectiveness and cost-benefit of rehabilitation in the community and transitional care with traditional hospital rehabilitation care.	There was no significant difference regarding length of stay in the two groups. Among the participants who were discharged from hospital, 17% and 13% were readmitted within 28 days, respectively. There were no significant differences between the groups in any secondary results. The cost difference between the two intervention strategies was estimated at 144 pounds.
S7(¹⁵15 Low LL, Tan SY, Ng MJ, Tay WY, Ng LB, Balasubramaniam K, Towle RM, Lee KH. Applying the Integrated Practice Unit Concept to a Modified Virtual Ward Model of Care for Patients at Highest Risk of Readmission: a randomized controlled trial. PLoS One. 2017;12(1):e0168757. https://doi.org/10.1371/journal.pone.0168757 https://doi.org/10.1371/journal.pone.016... )	Singapore 2017	Randomized clinical trial n=840 participants	Evaluating the effectiveness of a model that incorporates pre-hospital discharge transitional care in reducing the use of hospital services by people at a higher risk of readmission.	By applying the concept of practice unit integrated into the online nursing program, which incorporates pre-hospital discharge transitional care, the hospitalization rate was reduced by one third. Combining compatible concepts in care integration can produce synergic results, and more studies would be useful to confirm this idea. Care integration projects must adapt new concepts with the potential to be suitable for the settings under consideration and evaluate the results by designing controlled studies.
S8(¹⁶16 Hahn-Goldberg S, Jeffs L, Troup A, Kubba R, Okrainec K. "We are doing it together"; the integral role of caregivers in a patients' transition home from the medicine unit. PLoS One. 2018;13(5):e0197831. https://doi.org/10.1371/journal.pone.0197831 https://doi.org/10.1371/journal.pone.019... )	Canada 2018	Qualitative study n=27 participants	Exploring the factors that affect people’s ability to understand and follow indications.	Caretakers played an important role in the transition experienced by patients with chronic diseases and impacted people’s ability to understand and follow indications for discharge. The authors highlighted opportunities for managers and institutions to make the engagement of caretakers in the transition from hospital care to home care effective.
S9(¹⁷17 Chase JD, Russell D, Rice M, Abbott C, Bowles KH, Mehr DR. Caregivers' Perceptions Managing Functional Needs Among Older Adults Receiving Post-Acute Home Health Care. Res Gerontol Nurs. 2019;12(4):174-183. https://doi.org/10.3928/19404921-20190319-01 https://doi.org/10.3928/19404921-2019031... )	United States 2019	Qualitative study n=20 participants	Exploring the experiences of caretakers in the management of home care needs in post-acute health condition situations, regarding the functioning sphere.	Caretakers played an active and critical role in the management of elderly people’s needs when they returned home after hospitalization. Delivery of home care by nurses focused on supporting and training caretakers. Understanding caretakers’ perception regarding their activities and their role in the management of elderly people’s needs in all care transitions can provide resources for new studies and future practices in post-acute health condition situations.
S10(¹⁸18 Swanson JO, Moger TA. Comparisons of readmissions and mortality based on post-discharge ambulatory follow-up services received by stroke patients discharged home: a register-based study. BMC Health Serv Res. 2019 19(4). https://doi.org/10.1186/s12913-018-3809-z https://doi.org/10.1186/s12913-018-3809-... )	Norway 2019	Longitudinal observational quantitative study n=3,060 participants	Comparing readmission and mortality rates in two groups of people who had a cerebrovascular accident: one that received follow-up at home after hospital discharge and a control group that did not receive it.	There were no significant differences between the groups regarding readmission rate, despite early follow-up. The patients who got nursing support at home and/or rehabilitation care showed higher readmission rates after 90 and 365 days after hospital discharge in comparison with the control group. There were no significant differences regarding mortality rate. People who received rehabilitation care had a higher mortality rate, whereas those who were offered nursing support at home showed a rate similar to that obtained for the control group.
S11(¹⁹19 Van Spall HGC, Lee SF, Xie F. Effect of Patient-Centered Transitional Care Services on Clinical Outcomes in Patients Hospitalized for Heart Failure: The PACT-HF Randomized Clinical Trial. JAMA. 2019;321(8):753-761. https://doi.org/10.1001/jama.2019.0710 https://doi.org/10.1001/jama.2019.0710... )	Canada 2019	Randomized clinical trial n=2,494 participants	Testing the effectiveness of person-centered transitional care offered to inpatients with heart failure.	In the analyzed people with heart failure from Ontario, Canada, comparison between an implemented model of person-centered transitional care and traditional care indicated no improvements in clinical results. It is necessary to carry out more studies to test the effectiveness of this type of intervention. It may be effective in other systems or places.

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[1] Corresponding author: Ana Rita Cardoso Pedrosa, E-mail: anaritapedrosa@esel.pt