TABLE 2

Description of Family-Centered Transition Processes Used in Study Interventions

StudyStudy PopulationTransition ProcessDescription of Study’s Transition Process
Anderson et al28ElderlyTDECardiac nurse educator, dietician, and physical therapist provided targeted patient education. Home health care nurse with cardiac training implemented 6-wk home care plan: 6–10 visits enforcing education and self-management skills + 1 telephone call within 2 wk postdischarge.
PDFU
Balaban et al29AdultsTDEFloor nurse reviewed patient-tailored discharge form in the preferred language of communication. Patient given Patient Discharge Form, including diagnosis, names of hospital physicians, immunizations given, new allergies, diet and activity instructions, home services ordered, appointments, pending tests, recommended outpatient workup, and discharge medication list. Primary care office nurse called patient to confirm appointments and arrange urgent appointments within 24 h postdischarge. Primary care office nurse also assessed medical status, elicited questions or concerns, and arranged immediate interventions, such as medication refills during phone call.
ITR
SFU
PDFU
Chang et al38AdultsSFUDischarge appointment coordinators assisted patients and families in scheduling follow-up appointments before discharge by using 3-way conference calls.
Coleman et al30,31ElderlyTDETransition coach met with families to discuss a system for taking medications and other self-management skills, along with discussing red-flag warning symptoms or signs. Patient given Personalized Health Record, including active problem list, medications, allergies, and list of red flags. Transition coach provided advocacy in getting follow-up appointments as needed postdischarge. Transition coach scheduled a home visit within 24–72 h postdischarge and at least 3 follow-up phone calls within 24 d after discharge.
Parry et al36ITR
SFU
PDFU
Dedhia et al32ElderlyTNAHospitalists performed a comprehensive initial assessment, including transition needs on admission, and case manager created IDP by using input from patients and providers. Discharge planning nurse, discharging hospitalist provider, and patient/family participated in a discharge meeting in which written discharge information was reviewed with an emphasis on health literacy, and a medication grid was given.
TDE
Finn et al33AdultsTDEDischarge facilitator met with all patients to answer any questions about their discharge plan, medications, and appointments. Discharge facilitator called patients who were discharged over the weekend to follow-up on questions or concerns before PCP appointment.
PDFU
Hussain-Rizvi et al25Pediatric (ED)TDEPhysician demonstrated use of MDIS on first treatment, and parents administered subsequent treatments under supervision.
Jack et al34AdultsTDENurse discharge advocate provided diagnosis-specific education and used teach-back methodology to review transition record. Nurse discharge advocate reviewed barriers to keeping appointments and worked with patients and families to develop an After-Hospital Care Plan. Patient given After-Hospital Care Plan, including diagnosis, provider contact information of PCP and nurse discharge advocate, dates for appointments/tests with a calendar, pending results, and contingency plan information. Nurse discharge advocate made follow-up appointments with input from patients and families before discharge. Pharmacist called patient 2–4 d postdischarge to review medications and address medication-related problems, and then communicated problems to the PCP or nurse discharge advocate.
TNA
ITR
SFU
PDFU
Koehler et al35ElderlyTDECare coordinator provided daily condition-specific education, with extra discharge teaching regarding self-management and contingency plans when problems arise at home. Care coordinator provided additional time to address discharge barriers. Patient given Personalized Health Record, including active problem list, medications, allergies, and list of red flags. Care coordinator called patient and family 5–7 d postdischarge to confirm receipt of medical equipment, home health arrangements, and scheduling of follow-up appointments.
TNA
ITR
PDFU
Naylor et al39ElderlyTNAAdvanced practice nurse trained in heart failure performed comprehensive needs assessment during hospitalization, communicated patient needs to team, and developed an IDP with provider input. Advanced practice nurse provided at least 8 home visits postdischarge over 3 mo, along with telephone availability 7 d/wk.
PDFU
Patel et al27Pediatric (ED)TDEDischarge facilitator verbally reinforced written discharge instructions in parent’s language of choice before discharge from the ED.
Reese et al40AdultsPDFUHospitalists provided a home visit before the patient’s PCP appointment to assess the patient, home environment, and review medications, and communicated findings to PCP.
Yin et al26Pediatric (ED)TDERAs gave parents medication instruction sheets with pictograms to convey information about medication name, dose frequency, and preparation; and reviewed these instructions by using teach-back methods.
Zorc et al37Pediatric (ED)SFUStudy staff assisted caregivers of children with asthma in scheduling follow-up appointments with PCP during or immediately after ED visit.
  • IDP, individualized discharge plan; ITR, individualized transition record; MDIS, metered dose inhaler with spacer; PDFU, postdischarge telephone follow-up and home visits; SFU, assistance in scheduling follow-up appointments; TDE, patient and family-tailored discharge education; TNA, transition needs assessment.