Proposed health actions in care transition programs for older adults: an integrative review




Aged; Hospital Discharge; Patient Discharge; Care transition.


This study aimed to analyze the scientific evidence on health actions proposed in Transition of Care Programs for the elderly. The scope chosen for this study was an integrative review. The search strategy was carried out in the Virtual Health Library portal - which incorporates LILACS, BDENF and IBECS; as well as MEDLINE, SCOPUS, Embase and Web of Science, with controlled descriptors and non-controlled descriptors (key words) that were used to locate the articles. The searches occurred in the month of January 2021. The sample of articles elected for this integrative review was composed of 37 articles, with the years 2015 (n = 4), 2016 (n = 5), 2018 (n = 5), 2019 (n = 6) and 2020 (n = 5) being the years with the highest number of publications. As for the databases, no articles were found eligible in the VHL portal, which encompasses LILACS, IBECS and BDENF, to the detriment of the other bases in which the articles of this review were chosen, being them: Scopus (n = 12), Embase (n = 5), Web Of Science (n = 13), and Medline (n = 7). Transitional care programs for the elderly directly impact on improved medication adherence, better healthy lifestyles, and better clinical indicators, as well as lower rates of adverse events and hospital readmission, through health actions such as: patient and caregiver education while still in the hospital environment; telephone and home follow-up after discharge; medication supervision and management; and creation of individual therapeutic plans aimed at nutritional, physical, and cognitive rehabilitation.


Aboumatar, H., Naqibuddin, M., Chung, S., Chaudhry, H., Kim, S. W., Saunders, J., Bone, L., Gurses, A. P., Knowlton, A., Pronovost, P., Putcha, N., Rand, C., Roter, D., Sylvester, C., Thompson, C., Wolff, J. L., Hibbard, J. & Wise, R. A. (2019). Effect of a Hospital-Initiated Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Patients Hospitalized With Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial. Journal Of The American Medical Association, 322(14), 1371-1380.

Aboumatar, H., Naqibuddin, M., Chung, S., Chaudhry, H., Kim, S. W., Saunders, J., Bone, L., Gurses, A. P., Knowlton, A., Pronovost, P., Putcha, N., Rand, C., Roter, D., Sylvester, C., Thompson, C., Wolff, J. L., Hibbard, J. & Wise, R. A. (2018). Effect of a Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Hospitalized Patients With Chronic Obstructive Pulmonary Disease A Randomized Clinical Trial (Retracted article. See vol. 322, pg. 1417, 2019). Journal Of The American Medical Association, 320(22), 2335-2343.

Baecker, A., Meyers, M., Koyama, S., Taitano, M., Watson, H., Machado, M. & Nguyen, H. Q. (2020). Evaluation of a Transitional Care Program After Hospitalization for Heart Failure in an Integrated Health Care System. Jama Network Open, 3(12).

Ballard, J., Rankin, W., Roper, K. L., Weatherford, S. & Cardarelli, R. (2018). Effect of Ambulatory Transitional Care Management on 30-Day Readmission Rates. American journal of medical quality, 33(6), 583-589.

Ministério da Saúde (BR). (2013). Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. Cadernos de Atenção Básica, n. 36. Ministério da Saúde. Brasília, p. 160.

Burke, R. E. Kripalani, S., Vasilevskis, E. E. & Schnipper, J. L. (2013). Moving beyond readmission penalties: creating an ideal process to improve transitional care. Journal of Hospital Medicine, 8(2), 102-109.

Carret, M. L. V., Fassa, A. G., Paniz, V. M. V. & Soares, P. C. (2011). Características da demanda do serviço de saúde de emergência no sul do Brasil. Ciência & Saúde Coletiva, 16(1), 79-106.

Centeno, M. M. & Kahveci, K. L. (2014). Transitional care models: Preventing readmissions for high-risk patient populations. Critical Care Nursing Clinics of North America, 26(4), 589-597.

Coleman, E. A. & Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51(4), 556-7, 2003.

Crannage, A. J., Hennessey, E. K., Challen, L. M., Stevens, A. M. & Berry, T. M. (2020). Implementation of a Discharge Education Program to Improve Transitions of Care for Patients at High Risk of Medication Errors. Annals Of Pharmacotherapy, 54(6), 561-566.

Daliri, S., Kooij, M. J., Reimer, W. J. M. S. O., Riet, G., Jepma, P., Verweij, L., Peters, R. J. G., Buurman, B. M. & Karapinar-Carkit, F. (2021). Effects of a transitional care programme on medication adherence in an older cardiac population: A randomized clinical trial. British Journal Of Clinical Pharmacology.

Daley, C. M. (2010). A hybrid transitional care program. Critical Pathways In Cardiology, 9(4), 231-234.

Deng, A., Yang, S. & Xiong, R. (2020). Effects of an integrated transitional care program for stroke survivors living in a rural community: a randomized controlled trial. Clinical Rehabilitation, 34(4), 524-532.

Donaho, E. K., Hall, A. C., Gass, J. A., Elayda, M. A., Lee, V., Paire, S. & Meyers, D. E. (2015). Protocol-Driven Allied Health Post-Discharge Transition Clinic to Reduce Hospital Readmissions in Heart Failure. Journal Of The American Heart Association, 4(12).

Finlayson, K., Chang, A. M., Courtney, M. D., Edwards, H. E., Parker, A. W., Hamilton, K. Y. R. A., Pham, T. D. X. & O'Brien, J. (2018). Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults. BMC health services research, 18(1), 956-956.

Garcia, A. K. A., Fonseca L. F., Aroni P. & Galvão C. M. (2016). Strategies for thirst relief: integrative literature review. Revista Brasileira de Enfermagem, 69(6), 1148-55.

Goulart, F. A. A. (2011). Doenças Crônicas não Transmissíveis: Estratégias de controle e desafios para os sistemas de saúde. Organização Pan-Americana da Saúde, Ministério da Saúde. Brasília, p. 92.

Heim, N., Rolden, H., Van Fenema, E. M., Weverling-Rijnsburger, A.W.E., Tuijl, J. P., Jue, P., Oleksik, A. M., de Craen, A. J. M., Mooijaart, S. P., Blauw, G. J., Westendorp, R. G. J., Van Der Mast, R. C. & Van Everdinck, I. E. C. (2016). The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation. Age Ageing, 45(5), 642-651.

Hinch, B. K. & Staffileno, B. A. (2021). Implementing a Heart Failure Transition Program to Reduce 30-Day Readmissions. Journal for Healthcare Quality, 43(20, 110-118.

Huckfeldt, P. J., Reyes, B., Engstrom, G., Yang, Q., Diaz, S., Fahmy, S. & Ouslander, J. G. (2019). Evaluation of a Multicomponent Care Transitions Program for High-Risk Hospitalized Older Adults. Journal of the American Geriatrics Society, 67(12), 2634-2642.

Iseler, J., Fox, J. & Wierenga, K. (2018). Performance Improvement to Decrease Readmission Rates for Patients With a Left Ventricular Assist Device. Progress in transplantation, 28(2), 184-188.

Jepma, P., Verweij, L., Buurman, B. M., Terbraak, M. S., Daliri, S., Latour, C. H. M., Ter Riet, G., Karapinar-Çarkit, F., Dekker, J., Klunder, J. L., Liem, S. S., Moons, A. H. M., Peters, R. J. G. & Scholte Op Reimer, W. J. M. (2021). The nurse-coordinated cardiac care bridge transitional care programme: a randomised clinical trial. Age and ageing, 50(6), 2105-2115.

Kind, A. J., Jensen, L., Barczi, S., Bridges, A., Kordahl, R., Smith, M. A. & Asthana, S. (2012). Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at A VA hospital. Health Affairs, 31(12), 2659-2668.

Logue, M. D. & Drago, J. (2013). Evaluation of a modified community based care transitions model to reduce costs and improve outcomes. BMC Geriatrics, 13(1).

Lovelace, D., Hancock D., Hughes S. S., Wyche P. R., Jenkins C. & Logan, C. (2016). A Patient-Centered Transitional Care Case Management Program: Taking Case Management to the Streets and Beyond. Professional case management, 21(6), 277-290.

Low, L. L., Tan, S. Y., Ng, M. J. M., Tay, W. Y., Ng, L. B., Balasubramaniam, K., Towle, R. M. & Lee, K. H. (2017). 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, 2(1)

Low, L. L., Vasanwala, F. F., Ng, L. B., CHEN, C., Lee, K. H. & Tan, S. Y. (2015). Effectiveness of a transitional home care program in reducing acute hospital utilization: A quasi-experimental study. BMC Health Services Research, 15(1).

Mendes, K. S., Silveira, R. C. C. P. & Galvão, C. M. (2008). Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto – Enfermagem, 17(4), 758-764.

Melnyk, B. M. & Fineout-Overholt, E. (2001). Evidence-based practice in nursing & healthcare: a guide to best practice. Lippincott Williams & Wilkins.

Morrison, J., Palumbo, M. V. & Rambur, B. (2016). Reducing Preventable Hospitalizations With Two Models of Transitional Care. Journal of nursing scholarship, 48(3), 322-9.

Mourad, O., Hossam, H., Zbys F. & Adn A. E. (2016). Rayyan – a web and mobile app for systematic reviews. Systematic Reviews, 5, 20.

Murphy, J. A., Schroeder, M. N., Rarus, R. E., Yakubu, I., Mckee, S. O. P. & Martin, S. J. (2019). Implementation of a Cardiac Transitions of Care Pilot Program: A Prospective Study of Inpatient and Outpatient Clinical Pharmacy Services for Patients With Heart Failure Exacerbation or Acute Myocardial Infarction. Journal of Pharmacy Practice, 32(1), 68-76.

Naylor, M. D., Bowles, K. H., Mccauley, K. M., Maccoy, M. C., Maislin, G., Pauly, M. V. & Krakauer, R. (2013). High-value transitional care: Translation of research into practice. Journal of Evaluation in Clinical Practice, 19(5), 727-733.

Neu, R., Leonard, M. A., Dehoorne, M. L., Scalia, S. J., Kale-Pradhan, P. B. & Giuliano, C. A. (2020). Impact of Pharmacist Involvement in Heart Failure Transition of Care. Annals of Pharmacotherapy, 54(3),239-246.

Ornstein, K.,Smith, K. L., Foer D. H., Lopez-Cantor, M. T. & Soriano, T. T. (2011). The hospital and back home again: a nurse practitioner-based transitional care program for hospitalized homebound people. Journal of the American Geriatrics Society, 59(3), 544-51.

Poelzl, G., Egelseer-Bruendl, T., Pfeifer, B., Modre-Osprian, R., Welte, S., Fetz, B., Krestan, S., Haselwanter, B., Zaruba, M. M., Doerler, J., Rissbacher, C., Ammenwerth, E. & Bauer, A. (2021). Feasibility and effectiveness of a multidimensional post-discharge disease management programme for heart failure patients in clinical practice: the HerzMobil Tirol programme. Clinical Research In Cardiology.

Registered Nurses’ Association Of Ontario (2014). Care transitions. Clinical best practice guidelines. Toronto: RNAO.

Robertson, F. C, Logsdon, J. L., Dasenbrock, H. H., Yan, S. C., Raftery, S. M., Smith, T. R. & Gormley, W. B. (2018). Transitional care services: a quality and safety process improvement program in neurosurgery. Journal of neurosurgery, 128(5), 1570-1577.

Robinson, T. E., Zhou, L., Kerse, N., Scott, J. D. R., Christiansen, J. P., Holland, K., Armstrong, D. E. & Bramley, D. (2015). Evaluation of a New Zealand program to improve transition of care for older high risk adults. Australasian Journal on Ageing, 34(4), 269-274.

Rossetto, C., Soares J. V., Brandão, M. L., Rosa, N. G. & Rosset, I. (2019). Causas de internação hospitalar e óbito em idosos brasileiros entre 2005 e 2015. Revista Gaúcha de Enfermagem,40, e20190201.

Shimidt, M. I. (2011). Chronic non-communicable diseases in Brazil: burden and current challenges. The Lancet, 377(9781), 1949-1961.

Stauffer, B. D., Fullerton, C., Fleming, N., Ogola, G., Herrin, J., Stafford, P. M. & Ballard, D. J. (2011). Effectiveness and Cost of a Transitional Care Program for Heart Failure A Prospective Study With Concurrent Controls. Archives Of Internal Medicine, 171(14), 1238-1243.

Shu, C., Hsu, N., Lin, Y., Wang, J., Lin, J. K. & Wen J.E. (2011). Integrated postdischarge transitional care in a hospitalist system to improve discharge outcome: an experimental study. BMC Medicine, 9.

Takahashi, P. Y., Naessens, J. M., Peterson, S. M., Rahman, P. A., Shah, N. D., Finnie, D. M., Weymiller, A. J., Thorsteinsdottir, B. & Hanson, G. J. (2016). Short-term and long-term effectiveness of a post-hospital care transitions program in an older, medically complex population. Healthcare, 4(1), 30-35.

Vearing, R., Casey, S., Zaremba, C., Bowden, S., Ferguson, A., Goodisson, C., Potter, J., Evry, N. & Charlton, K. (2019). Evaluation of the impact of a post-hospital discharge Transitional Aged Care Service on frailty, malnutrition and functional ability. Nutrition and Dietetics, 76(4), 472-479.

Warren, C., Lemieux, A. A. & Bittner, N. P. (2019). Excellence in Population Health A Successful Community-Based Care Transitions Program Model. Professional Case Management, 24(1), 39-45.

Wee, S., Loke, C., Liang, C., Ganesan, G., Wong, L. & Cheah, J. (2014). Effectiveness of a National Transitional Care Program in Reducing Acute Care Use. Journal Of The American Geriatrics Society, 62(4), 747-753.

Wong, F. K. Y. & Yeung, S. M. (2015). Effects of a 4-week transitional care programme for discharged stroke survivors in Hong Kong: A randomised controlled trial. Health and Social Care in the Community, 23(6), 619-631.

Wong F.K., Ng A., Lee P.H., Lam P.T., Ng J.S., Ng N.H. & Sham M.M. (2016). Effects of a transitional palliative care model on patients with end-stage heart failure: a randomised controlled trial. Heart (British Cardiac Society), 102(14), 1100-1108.

Wong A. K. C., Wong F. K. Y., Ngai J. S. C., Hung S. Y. K. & Li W. C. (2020). Effectiveness of a health-social partnership program for discharged non-frail older adults: a pilot study. BMC geriatrics, 20(1), 339.

Wu, Q., Zhang, D., Zhao, Q., Liu, L., He, Z., Chen, Y., Huang, H., Hou, Y., Yang, X. & Gu, J. (2019). Effects of transitional health management on adherence and prognosis in elderly patients with acute myocardial infarction in percutaneous coronary intervention: A cluster randomized controlled trial. PLoS ONE, 14(5).



How to Cite

PETROCINI, R. K. .; TOMAZELA, M.; AMARAL, G. G. .; SILVA, B. S. .; PINTO, I. C. .; ZACHARIAS, F. C. M. . Proposed health actions in care transition programs for older adults: an integrative review . Research, Society and Development, [S. l.], v. 11, n. 3, p. e35611326591, 2022. DOI: 10.33448/rsd-v11i3.26591. Disponível em: Acesso em: 22 jul. 2024.



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