Facilitating Equitable Subacute-to-Home Transitions for Patients Receiving Palliative and/or End-of-Life Care: A Literature Review
DOI:
https://doi.org/10.15273/hpj.v3i2.11589Schlagworte:
Subacute-to-home transitions, Care transitions, Palliative care, End-of-life care, Home and community care, Health services research, Health care equityAbstract
Introduction: As people in subacute facilities approach the end of life, the focus of their care often shifts to comfort as they seek to return home. Interventions that aim to improve hospital-to-home transitions do not generally focus on subacute care. Objective: To summarize the existing literature on subacute-to-home transitions for individuals receiving palliative care near the end of life, and to explore whether these interventions are targeted toward marginalized groups to improve their transition experience. Methods: We searched the MEDLINE, Embase, HealthSTAR, and Cochrane Library electronic databases using terms related to end of life, palliative care, and transitions from subacute facilities to home. We identified 896 records and included 29 articles, 11 of which were intervention articles. We searched the 11 intervention articles for equity stratifiers. Results: Of the 29 included articles, four addressed transitions for end-of-life populations, three discussed family caregiver perspectives, and 11 were intervention studies, including regular home visit follow-ups, individualized transition care plans, and an individualized intervention with an advanced practice nurse. Subacute-to-home interventions showed positive outcomes such as reduced risk of hospital readmissions, reduced length of stays, and improved functional status. However, study limitations included small sample sizes, inconsistent definitions of outcomes, and incompletion due to COVID-19. No studies focused on marginalized groups. Conclusion/Discussion: While there was some literature supporting targeted interventions for subacute-to-home transitions for those receiving palliative care or end-of-life care, the included interventions did not target marginalized groups. Further research in these areas is required.
Literaturhinweise
Albert, N. M. (2016). A systematic review of transitional-care strategies to reduce rehospitalization in patients with heart failure. Heart & Lung, 45(2), 100–113. https://doi.org/10.1016/j.hrtlng.2015.12.001
Aso, S., Hayashi, N., Sekimoto, G., Nakayama, N., Tamura, K., Yamamoto, C., Aoyama, M., Morita, T., Kizawa, Y., Tsuneto, S., Shima, Y., & Miyashita, M. (2022). Association between temporary discharge from the inpatient palliative care unit and achievement of good death in end-of-life cancer patients: A nationwide survey of bereaved family members. Japan Journal of Nursing Science, 19(3), Article e12474. https://doi.org/10.1111/jjns.12474
Canadian Institute for Health Information. (2018, April). In pursuit of health equity: Defining stratifiers for measuring health inequality. https://www.cihi.ca/sites/default/files/document/defining-stratifiers-measuring-health-inequalities-2018-en-web.pdf
Coleman, E. A., Smith, J. D., Frank, J. C., Min, S.-J., Parry, C., & Kramer, A. M. (2004). Preparing patients and caregivers to participate in care delivered across settings: The Care Transitions Intervention. Journal of the American Geriatrics Society, 52(11), 1817–1825. https://doi.org/10.1111/j.1532-5415.2004.52504.x
Davis, J., Morgans, A., & Stewart, J. (2016). Developing an Australian health and aged care research agenda: A systematic review of evidence at the subacute interface. Australian Health Review, 40(4), 420–427. https://doi.org/10.1071/AH15005
Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743–1748. https://doi.org/10.1001/jama.1988.03410120089033
Donabedian, A. (2005). Evaluating the quality of medical care. The Milbank Quarterly, 83(4), 691–729. https://doi.org/ 10.1111/j.1468-0009.2005.00397.x
Elliott, R. A. (2012). Reducing medication regimen complexity for older patients prior to discharge from hospital: Feasibility and barriers. Journal of Clinical Pharmacy and Therapeutics, 37(6), 637–642. https://doi.org/ 10.1111/j.1365-2710.2012.01356.x
Freeman, H. P., & Rodriguez, R. L. (2011). History and principles of patient navigation. Cancer, 117(S15), 3539–3542. https://doi.org/10.1002 /cncr.26262
Hall, R. K., Toles, M., Massing, M., Jackson, E., Peacock-Hinton, S., O‘Hare, A. M., & Colón-Emeric, C. (2015). Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities. Clinical Journal of the American Society of Nephrology, 10(3), 428–434. https://doi.org/10.2215 /cjn.03510414
Hansen, F. R., Poulsen, H., & Sà¸rensen, K. H. (1995). A model of regular geriatric follow-up by home visits to selected patients discharged from a geriatric ward: A randomized controlled trial. Aging Clinical and Experimental Research, 7(3), 202–206. https://doi.org/10.1007/BF03324316
Health Quality Ontario. (n.d.). Quality Improvement Plan guidance: Using sociodemographic data for targeted improvement. https://www.hqontario.ca/Portals/0/documents/qi/qip/qip-guidance-sociodemographic-data-en.pdf
Isenberg, S. R., Bonares, M., Kurahashi, A. M., Algu, K., & Mahtani, R. (2022). Race and birth country are associated with discharge location from hospital: A retrospective cohort study of demographic differences for patients receiving inpatient palliative care. eClinical Medicine, 45, Article 101303. https://doi.org/10.1016/j.eclinm.2022.101303
Johnson, K. S. (2013). Racial and ethnic disparities in palliative care. Journal of Palliative Medicine, 16(11), 1329–1334. https://doi.org/10.1089/jpm.2013.9468
Killackey, T., Lovrics, E., Saunders, S., & Isenberg, S. R. (2020). Palliative care transitions from acute care to community-based care: A qualitative systematic review of the experiences and perspectives of health care providers. Palliative Medicine, 34(10), 1316–1331. https://doi.org/10.1177 /0269216320947601
Lee, J. Y., Yang, Y. S., & Cho, E. (2022). Transitional care from hospital to home for frail older adults: A systematic review and meta-analysis. Geriatric Nursing, 43, 64–76. https://doi.org/ 10.1016/j.gerinurse.2021.11.003
Lenaghan, N. A. (2019). Transitional care and empowerment of the older adult. Geriatric Nursing, 40(2), 148–153. https://doi.org/10.1016/j.gerinurse.2018.07.005
Li, J., Young, R., & Williams, M. V. (2014). Optimizing transitions of care to reduce rehospitalizations. Cleveland Clinic Journal of Medicine, 81(5), 312–320. https://doi.org/10.3949/ccjm.81a.13106
Li, M., Porter, E., Lam, R., & Jassal, S. V. (2007). Quality improvement through the introduction of interdisciplinary geriatric hemodialysis rehabilitation care. American Journal of Kidney Diseases, 50(1), 90–97. https://doi.org/ 10.1053/j.ajkd.2007.04.011
Makam, A. N., Tran, T., Miller, M. E., Xuan, L., Nguyen, O. K., & Halm, E. A. (2019). The clinical course after long-term acute care hospital admission among older Medicare beneficiaries. Journal of the American Geriatrics Society, 67(11), 2282–2288. https://doi.org/ 10.1111/jgs.16106
Masel, E. K., Huber, P., Schur, S., Kierner, K. A., Nemecek, R., & Watzke, H. H. (2014). Predicting discharge of palliative care inpatients by measuring their heart rate variability. Annals of Palliative Medicine, 3(4), 244–249. https://doi.org/10.3978/j.issn.2224-5820.2014.08.01
Masel, E. K., Huber, P., Schur, S., Kierner, K. A., Nemecek, R., & Watzke, H. H. (2015). Coming and going: Predicting the discharge of cancer patients admitted to a palliative care unit: Easier than thought? Supportive Care in Cancer, 23(8), 2335–2339. https://doi.org/ 10.1007/s00520-015-2601-4
Menzies, O. H., & Hanger, H. C. (2011). Resource usage and outcomes in a facilitated discharge service in Christchurch, New Zealand. New Zealand Medical Journal, 124(1341), 29–37. https://journal.nzma.org.nz/journal-articles/resource-usage-and-outcomes-in-a-facilitated-discharge-service-in-christchurch-new-zealand
Middleton, A., Graham, J. E., Prvu Bettger, J., Haas, A., & Ottenbacher, K. J. (2018). Facility and geographic variation in rates of successful community discharge after inpatient rehabilitation among Medicare fee-for-service beneficiaries. JAMA Network Open, 1(7), Article e184332. https://doi.org/10.1001%2Fjamanetworkopen.2018.4332
Morkisch, N., Upegui-Arango, L. D., Cardona, M. I., van den Heuvel, D., Rimmele, M., Sieber, C. C., & Freiberger, E. (2020). Components of the transitional care model (TCM) to reduce readmission in geriatric patients: A systematic review. BMC Geriatrics, 20, Article 345. https:// doi.org/10.1186/s12877-020-01747-w
Murmann, M., Sinden, D., Hsu, A. T., Thavorn, K., Eddeen, A. B., Sun, A. H., & Robert, B. (2023). The cost-effectiveness of a nursing home-based transitional care unit for increasing the potential for independent living in the community among hospitalized older adults. Journal of Medical Economics, 26(1), 61–69. https://doi.org/10.1080 /13696998.2022.2156152
NHS England. (2021, September). Quality, service improvement and redesign: Providing participants with the know-how to design and implement more efficient and productive services. Retrieved from https://www.england.nhs.uk/wp-content/uploads/2021/09/Quality-service-improvement-and-redesign-programmes-providing-participants-with-the-know-how-to-design-and-imp.pdf
Nikolaus, T., Specht-Leible, N., Bach, M., Oster, P., & Schlierf, G. (1999). A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients. Age and Ageing, 28(6), 543–550. https:// doi.org/10.1093/ageing/28.6.543
Ohta, R., Maeki, N., Maniwa, S., & Miyakoshi, K. (2021). Predicting factors of elderly patients‘ discharge to home after rehabilitation in rural Japan: A retrospective cohort study. Rural & Remote Health, 21(1), Article 6406. https://doi.org/10.22605/rrh6406
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., . . . Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71
Piraino, E., Heckman, G. A., Glenny, C., & Stolee, P. (2012). Transitional care programs: Who is left behind? A systematic review. International Journal of Integrated Care, 12(July–September), Article e132. https://doi.org/10.5334/ijic.805
Premier‘s Council on Improving Healthcare and Ending Hallway Medicine. (2019, January). Hallway health care: A system under strain. Government of Ontario. http://www.health.gov.on.ca/en/public/publications/premiers_council/docs/premiers_council_report.pdf
Reyes-Ortiz, C. A., Williams, C., & Westphal, C. (2015). Comparison of early versus late palliative care consultation in end-of-life care for the hospitalized frail elderly patients. American Journal of Hospice & Palliative Medicine, 32(5), 516–520. https://doi.org/10.1177/1049909114530183
Robert, B., Sun, A. H., Sinden, D., Spruin, S., & Hsu, A. T. (2021). A case-control study of the Sub-Acute care for Frail Elderly (SAFE) Unit on hospital readmission, emergency department visits and continuity of post-discharge care. JAMDA, 22(3), 544–550. https://doi.org/10.1016/j.jamda.2020.07.020
Rodham, K., Boxell, E., McCabe, C., Cockburn, M., & Waller, E. (2012). Transitioning from a hospital rehabilitation programme to home: Exploring the experiences of people with complex regional pain syndrome. Psychology & Health, 27(10), 1150–1165. https://doi.org/10.1080/08870446.2011.647820
Rose, T., Frith, K., & Zimmer, R. (2021). Transitional care following a skilled nursing facility stay: Utilization of nurse practitioners to reduce readmissions in high risk older adults. Geriatric Nursing, 42(6), 1594–1596. https://doi.org/ 10.1016/j.gerinurse.2021.06.024
Runacres, F., Gregory, H., & Ugalde, A. (2016). Restorative care for palliative patients: A retrospective clinical audit of outcomes for patients admitted to an inpatient palliative care unit. BMJ Supportive & Palliative Care, 6(1), 97–100. https://doi.org/10.1136 /bmjspcare-2014-000774
Santa-Emma, P. H., Roach, R., Gill, M. A., Spayde, P., & Taylor, R. M. (2002). Development and implementation of an inpatient acute palliative care service. Journal of Palliative Medicine, 5(1), 93–100. https://doi.org/10.1089/10966210252785051
Saunders, S., Killackey, T., Kurahashi, A., Walsh, C., Wentlandt, K., Lovrics, E., Scott, M., Mahtani, R., Bernstein, M., Howard, M., Tanuseputro, P., Goldman, R., Zimmermann, C., Aslakson, R. A., Isenberg, S. R., & American Academy of Hospice Palliative Medicine Research Committee Writing Group. (2019). Palliative care transitions from acute care to community-based care—A systematic review. Journal of Pain & Symptom Management, 58(4), 721–734. https://doi.org/10.1016/j.jpainsymman.2019.06.005
Scott, M., Shaver, N., Lapenskie, J., Isenberg, S. R., Saunders, S., Hsu, A. T., & Tanuseputro, P. (2020). Does inpatient palliative care consultation impact outcomes following hospital discharge? A narrative systematic review. Palliative Medicine, 34(1), 5–15. https://doi.org/ 10.1177/0269216319870649
Shea, T., De Cieri, H., Donohue, R., Cooper, B., & Sheehan, C. (2016). Leading indicators of occupational health and safety: An employee and workplace level validation study. Safety Science, 85, 293–304. https://doi.org/10.1016 /j.ssci.2016.01.015
Sheehan, C., Donohue, R., Shea, T., Cooper, B., & De Cieri, H. (2016). Leading and lagging indicators of occupational health and safety: The moderating role of safety leadership. Accident Analysis and Prevention, 92, 130–138. https:// doi.org/10.1016/j.aap.2016.03.018
Shinall, M. C., Jr., Wilson, J. E., Karlekar, M., & Ely, E. W. (2019). Facility placement as a barrier to hospice for older adult patients discharged from a palliative care unit. American Journal of Hospice & Palliative Medicine, 36(2), 93–96. https://doi.org/10.1177/1049909118791149
Sinn, C.-L. J., Tran, J., Pauley, T., & Hirdes, J. (2016). Predicting adverse outcomes after discharge from complex continuing care hospital settings to the community. Professional Case Management, 21(3), 127–136. https://doi.org/10.1097/NCM.0000000000000148
Squires, A., Ma, C., Miner, S., Feldman, P., Jacobs, E. A., & Jones, S. A. (2022). Assessing the influence of patient language preference on 30 day hospital readmission risk from home health care: A retrospective analysis. International Journal of Nursing Studies, 125, Article 104093. https://doi.org/10.1016/j.ijnurstu.2021.104093
Toles, M., Colón-Emeric, C., Hanson, L. C., Naylor, M., Weinberger, M., Covington, J., & Preisser, J. S. (2021). Transitional care from skilled nursing facilities to home: Study protocol for a stepped wedge cluster randomized trial. Trials, 22, Article 120. https://doi.org/10.1186 /s13063-021-05068-0
Trillig, A. U., Ljuslin, M., Mercier, J., Harrisson, M., & Vayne-Bossert, P. (2022). “I am not the same man...”: A case report of management of post-COVID refractory dyspnea. Journal of Palliative Medicine, 25(10), 1606–1609. https://doi.org/ 10.1089/jpm.2021.0605
Tunnard, I., Yi, D., Ellis-Smith, C., Dawkins, M., Higginson, I. J., & Evans, C. J. (2021). Preferences and priorities to manage clinical uncertainty for older people with frailty and multimorbidity: A discrete choice experiment and stakeholder consultations. BMC Geriatrics, 21, Article 553. https://doi.org/10.1186%2Fs12877-021-02480-8
Tyler, I., Amare, H., Hyndman, B., & Manson, H. (2014, October). Health equity assessment: Facilitators and barriers to application of health equity tools. Public Health Ontario. https://www.publichealthontario.ca/-/media/documents/h/2014/health-equity-barriers.pdf
Walker, R., Johns, J., & Halliday, D. (2015). How older people cope with frailty within the context of transition care in Australia: Implications for improving service delivery. Health & Social Care in the Community, 23(2), 216–224. https://doi.org/10.1111/hsc.12142
Webber, C., Hsu, A. T., Tanuseputro, P., Fitzgibbon, E., & Li, C. (2020). Acute care utilization and place of death among patients discharged from an inpatient palliative care unit. Journal of Palliative Medicine, 23(1), 54–59. https: //doi.org/10.1089/jpm.2019.0162
Wilson, D. M., & Birch, S. (2018). Moving from place to place in the last year of life: A qualitative study identifying care setting transition issues and solutions in Ontario. Health & Social Care in the Community, 26(2), 232–239. https://doi.org/10.1111/hsc.12513
Yarnell, C. J., Fu, L., Bonares, M. J., Nayfeh, A., & Fowler, R. A. (2020). Association between Chinese or South Asian ethnicity and end-of-life care in Ontario, Canada. CMAJ, 192(11), E266–E274. https://doi.org/10.1503/cmaj.190655
Yarnell, C. J., Fu, L., Manuel, D., Tanuseputro, P., Stukel, T., Pinto, R., Scales, D. C., Laupacis, A., & Fowler, R. A. (2017). Association between immigrant status and end-of-life care in Ontario, Canada. JAMA, 318(15), 1479–1488. https:// doi.org/10.1001/jama.2017.14418
Zengin, H., & TaŠŸçi, I. (2021). Factors influencing the length of stay in the palliative care unit in patients discharged home: Results from a tertiary hospital in Turkey. Turkish Journal of Medical Sciences, 51(5), 2420–2426. https://doi.org/ 10.3906/sag-2101-307
Zhang, H., Barysauskas, C., Rickerson, E., Catalano, P., Jacobson, J., Dalby, C., Lindvall, C., & Selvaggi, K. (2017). The intensive palliative care unit: Changing outcomes for hospitalized cancer patients in an academic medical center. Journal of Palliative Medicine, 20(3), 285–289. https://doi.org/10.1089 /jpm.2016.0225
Downloads
Veröffentlicht
Ausgabe
Rubrik
Lizenz
Copyright (c) 2023 Madeline McCoy, Ladees Al Hafi, Ariane Downar,Taylor Shorting, Krystal Kehoe MacLeod, Shirley H. Bush, Aria Wills, Geneviève Lalumière, Jill Rice, Sarina R. Isenberg
Dieses Werk steht unter der Lizenz Creative Commons Namensnennung - Nicht-kommerziell 4.0 International. The journal aims to reduce barriers to publishing and sharing research and inequalities to accessing information.This journal provides immediate open access to its content on the principle that making research freely available to the public supports a greater global exchange of knowledge. The open-access nature of the journal means that there will be no charge for authors or readers to use the journal. The journal has a Creative Commons Attribution Non-Commercial (CCBYNC) attribution which allows the author (and others) to share and distribute their full-text article in other public domains, such as Google Scholar or Research Gate.