Nurse-Led Home-Visit Transitional Care Programs for People Discharged from Hospital to Home: A Scoping Review

ABSTRACT

Introduction/Rationale People with multiple chronic diseases, such as heart failure (HF) or chronic obstructive pulmonary disease (COPD), are at elevated risk of unplanned repeated hospitalization. Transitional care has been recognized as reducing unexpected rehospitalization after discharge from hospital to home. As the COVID-19 pandemic is prolonged, individual home healthcare services are getting increased attention for post-acute care. However, less is known about the effectiveness of nurse-led transitional care programs, including home-visit intervention. Objectives: This study aimed to identify the effectiveness of nurse-led home-visit transitional care programs in improving health service utilization, functional status, and quality of life (QoL) among people discharged from hospital to home. Methods: We conducted a scoping review of the EBSCOMedline, Cochrane Library and Embase databases searching for articles containing a combination of “home care,” “transitional care,” and “care coordination” between 1973 and 2021. Inclusion criteria were randomized controlled trials (RCTs) or quasi-experimental studies, adults who need continuing healthcare after discharged to home, and affecting at least one of the following outcomes: hospital readmission, functional status, and QoL. Results: Initial searching identified 1552 potential records, 1328 s were screened, and 105 full texts were retrieved. A total of 16 studies met the selection criteria. Seven studies were conducted in North America and most were RCTs (n=14). Most participants (mean=73 years) had multiple chronic diseases, such as stroke, COPD, or HF. Regarding discharge plans, two-thirds of the studies included a pre-and a post-discharge plan (n=11). All studies included a home-visit intervention regularly or as needed over a period from one week to two years. Intervention team providers were the research team only (n=2), a collaboration with a hospital team (n=4), a community team (n=4), or a hospital team plus a community team (n=6). Hospital readmissions were assessed in 12 studies and found to be significantly lower in the intervention group (n=4). Physical function status was assessed in seven studies and was significantly better in the intervention group (n=2). QoL was assessed in eight studies and was significantly greater in the intervention group (n=3). Conclusions: About 30% of the studies reported that home-visit transitional care interventions had positive effects on hospital readmissions, physical function status, and QoL. More studies are required to include patient engagement and the use of technology, such as telehealth, in transitional care plans to improve selfcare at home.