Interventions to promote older adult functionality in the hospital-to-home transition: an integrative review

Amorim, Renata Farias; Pedreira, Larissa Chaves; Martinez, Bruno Prata; Gomes, Nildete Pereira; Sampaio, Rute dos Santos; Damasceno, Anita Gabriele de Jesus

doi:10.1590/1981-22562024027.230227.en

Renata Farias Amorim

conception, design, analysis and interpretation of data

drafting of the paper

approval of the version to be published

and being responsible for all aspects of the work, ensuring that issues related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Universidade Federal da Bahia, Programa de Pós-Graduação em Enfermagem e Saúde. Salvador, BA, Brasil.

Empresa Brasileira de Serviços Hospitalares, Unidade Multiprofissional. Salvador, BA, Brasil.

https://orcid.org/0000-0003-3591-3443

Larissa Chaves Pedreira

drafting of the paper and its critical review

approval of the version to be published.

Universidade Federal da Bahia, Programa de Pós-Graduação em Enfermagem e Saúde. Salvador, BA, Brasil.

https://orcid.org/0000-0001-8939-324X

Bruno Prata Martinez

drafting of the paper and its critical review

approval of the version to be published.

Universidade Federal da Bahia, Programa de Pós-graduação em Medicina e Saúde. Salvador, BA, Brasil.

https://orcid.org/0000-0002-4673-8698

Nildete Pereira Gomes

drafting of the paper and its critical review

approval of the version to be published.

Universidade Federal da Bahia, Programa de Pós-Graduação em Enfermagem e Saúde. Salvador, BA, Brasil.

https://orcid.org/0000-0002-1690-4122

Rute dos Santos Sampaio

data interpretation

drafting of the paper.

Universidade Federal da Bahia, Programa de Pós-Graduação em Enfermagem e Saúde. Salvador, BA, Brasil.

https://orcid.org/0000-0002-3395-9029

Anita Gabriele de Jesus Damasceno

analysis and interpretation of data

drafting of the paper.

Universidade Federal da Bahia, Departamento de Fisioterapia. Salvador, BA, Brasil.

https://orcid.org/0009-0002-8674-5101

Correspondence Renata Farias Amorim renyamorim@yahoo.com.br

The authors declare that there is no conflict in the conception of this work.

Edited by: Marquiony Marques dos Santos

Database	Search Strategy
MEDLINE via PubMed	((((((("Aged"[Mesh]) OR (Elderly)) OR (Older)) OR (Senior)) OR (Elder)) OR (Geriatric)) AND (((((((("Functional Status"[Mesh]) OR (Status, Functional)) OR (Functional Independence)) OR (Independence, Functional)) OR (Functional Dependence)) OR (Functional Disability)) OR (Functional Ability)) OR (Functional Capacity))) AND (((((("Transitional Care"[Mesh]) OR (Care, Transitional)) OR (Transitional Cares)) OR (Transition Care)) OR (Home Transition)) OR (Transition*, Home))
LILACS, BDENF, IBECS via BVS	((mh:(aged)) OR (elderly) OR (older) OR (senior) OR (elder) OR (geriatric)) AND ((mh:(functional status)) OR (status, functional) OR (functional independence) OR (functional dependence) OR (functional disability) OR (functional ability) OR (functional capacity)) AND ((mh:(transitional care)) OR (care, transitional) OR (transitional cares) OR (transition care) OR (home transition) OR (transition* home))
Web of Science	((TS=(Aged)) OR ALL=(Elderly OR Older OR Senior* OR Elder* OR Geriatric)) AND ((TS=(“Functional Status")) OR TS=(“Status, Functional" OR "Functional Independence" OR "Independence, Functional" OR "Functional Dependence" OR “Functional Disability” OR “Functional Ability” OR “Functional Capacity”)) AND ((TS=(“Transitional Care”)) OR ALL=(“Care, Transitional” OR “Transitional Cares” OR “Transition Care” OR “Home Transition” OR “Transition*, Home”))
SCOPUS	TITLE-ABS-KEY((Aged OR Elderly OR Older OR Senior* OR Elder* OR Geriatric) AND ("Functional Status" OR "Status, Functional" OR "Functional Independence" OR "Independence, Functional" OR "Functional Dependence" OR "Functional Disability" OR "Functional Ability" OR "Functional Capacity") AND ("Transitional Care" OR "Care, Transitional" OR "Transitional Cares" OR "Transition Care" OR "Home Transition" OR "Transition*, Home"))
CINAHL	(MH Aged OR Aged OR Elderly OR Older OR Senior* OR Elder* OR Geriatric* ) AND ( MH "Functional Status" OR "Functional Status" OR "Status, Functional" OR "Functional Independence" OR "Independence, Functional" OR "Functional Dependence" OR "Functional Disability" OR "Functional Ability" OR "Functional Capacity" ) AND ( MH "Transitional Care" OR "Transitional Care" OR "Care, Transitional" OR "Transitional Cares" OR "Transition Care" OR "Home Transition" OR "Transition, Home" )
Cochrane	(Aged OR Elderly OR Older OR Senior* OR Elder* OR Geriatric):ti,ab,kw AND (“Functional Status" OR “Status, Functional" OR "Functional Independence" OR "Independence, Functional" OR "Functional Dependence" OR “Functional Disability” OR “Functional Ability” OR “Functional Capacity”):ti,ab,kw AND (“Transitional Care” OR “Care, Transitional” OR "Cares, Transitional" OR “Transitional Cares” OR “Transition Care” OR “Home Transition*” OR “Transition, Home” OR "Transitions, Home"):ti,ab,kw
PEDro	Transition* Care* AND Gerontology

Authors Year Country Language	Design/ Level of Evidence/ Participants	Objective	Interventions	Main Results
Naylor et al, 2004¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x https://doi.org/10.1111/j.1532-5415.2004... , United States English	Randomized Controlled Trial Level of Evidence: I Participants: n = 239	Examining the effect of a three-month transitional care intervention, led by advanced practice nurses, for older adults hospitalized with heart failure on time to first readmission or death, total rehospitalizations, readmissions due to heart failure and comorbidities, quality of life, functional status, patient satisfaction, and healthcare costs.	CG: Routine care for the admitting hospital, including a site-specific protocol for heart failure. IG: Hospital and home visits conducted by advanced practice nurses from hospital admission up to three months post-discharge.	There was no statistically significant difference between the groups, although better functionality was observed in the IG.
Courtney et al, 2012¹⁴14 Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Bradbury C, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34. Disponível em: 10.1111/j.1365-2753.2010.01547.x, Australia English	Randomized Controlled Trial Level of Evidence: I Participants: n = 128	Assessing the effectiveness of a multifaceted transitional care intervention for older adults, comprising in-hospital and at-home exercises, on functional status and independence in ADLs.	CG: Routine care, discharge planning, follow-up, and rehabilitation counseling. IG: In addition to routine care, during hospitalization, received an individualized exercise program to improve balance, muscle strength, and flexibility; maintenance of health promotion behaviors; home visits and follow-up phone calls for up to 24 weeks post-discharge.	Improvement in functional capacity, independence in ADLs, and walking ability was observed in the IG compared to the CG.
Xueyu et al, 2017¹⁵15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02, China English	Randomized Controlled Trial Level of Evidence: I Participants: n = 83	Investigating the effect of an exercise protocol initiated during hospitalization on health-related quality of life, physical function, and cardiac function in older adults with Chronic Heart Failure during the transitional period.	CG: TC program including an individualized discharge plan, guidance on managing CHF, and 7 follow-up calls over 3 months. IG: TC program and a physical training protocol during hospitalization, consisting of 5 to 10 minutes of warm-up, followed by walking and 5 to 10 minutes of relaxation exercises. Post-discharge follow-up followed the same method and duration as CG.	Significant improvement in functional capacity was observed in the IG compared to the CG during the 12-week follow-up.
Carvalho et al, 2019¹⁶16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143, Canada English	Prospective Comparative Pilot Study of Before and After Type Level of Evidence: III Participants: n = 29	Developing a decision tree for prescribing an individualized and unsupervised home-based PA program for older adults post-hospital discharge; investigating feasibility, acceptability, and effectiveness on physical function and mobility.	Decision tree consisting of: physical assessment and identification of mobility profile; 1 or 2 training sessions of PA programs during hospitalization; logbook with recommendations on safe exercise practice and a weekly calendar for recording home sessions; weekly phone calls to address any questions. The intervention lasted for 12 weeks.	The use of a decision tree to support exercise prescription appears to be effective in improving physical function and mobility in patients discharged from geriatric units.
Geng et al, 2019¹⁷17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650, China English	Randomized Controlled Trial Level of Evidence: II Participants: n = 60	Assessing the impact of transition care, based on the Integrated Behavioral Model, on health behaviors and clinical outcomes related to cerebrovascular accident in older adults post-discharge.	CG: Routine health education before discharge and telephone follow-up one week after discharge. IG: TC divided into two stages: health education before discharge through informational booklet; weekly home visits and telephone follow-up, between 1 and 3 months post-discharge, by nurses and other healthcare professionals.	TC intervention demonstrated gains in performing ADLs.
Ko et al, 2019¹⁸18 Ko Y, Lee J, Oh E, Choi M, Kim C, Sung K, et al. Older Adults With Hip Arthroplasty: An Individualized Transitional Care Program. Rehabil Nurs Off J Assoc Rehabil Nurses. 2019;44(4):203–12. Disponível em: 10.1097/rnj.0000000000000120, South Korea English	Quasi-Experimental Study Level of Evidence: III Participants: n = 37	Assessing the effects of an individualized transitional care program based on a transitional theory to reduce functional decline in older adults undergoing hip arthroplasty for hip fracture.	CG: Routine postoperative care and health education before discharge. EG: In addition to the same care as CG, received a program consisting of nursing therapeutics, such as assessment, education, supportive environment through transition theory. Included exercise prescription. Conducted 6 times in 2 weeks, during hospitalization.	The CG and EG were significantly different in ADL scores between pre-fracture and post-intervention. The EG showed better scores. The intervention results were beneficial for functional mobility, with shorter times recorded in the TUG test.
Kitzman et al, 2021¹⁹19 Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021;385(3):203–16. Disponível em: 10.1056/NEJMoa2026141, United States English	Randomized Controlled Trial Level of Evidence: I Participants: n = 349	Evaluating the effectiveness of REHAB-HF in physical function and reduction of readmission rates for older adults hospitalized for decompensated acute heart failure.	CG: Routine care, phone call every 2 weeks, and visits at 1 month and 3 months post-discharge. IG: In addition to routine care, a rehabilitation program focused on domains of physical function (strength, balance, mobility, and endurance), which progressed through predefined functional levels. It comprised three phases: hospital-based, outpatient, and independent maintenance at home with telephone follow-up. The intervention lasted for 6 months.	The program resulted in significantly greater improvement in physical function in the IG compared to the CG.
Coskun, Duygulu, 2022²⁰20 Coskun S, Duygulu S. The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46–55. Disponível em: 10.1093/eurjcn/zvab005, Turkey English	Randomized Controlled Trial Level of Evidence: I Participants: n = 66	Assessing the effectiveness of the Transitional Care Model on functional autonomy, quality of life, readmission rates, and rehospitalization of older adults undergoing open-heart surgery.	CG: Routine healthcare practices. IG: Care based on the "Clinical Pathway for Open Heart Surgery" and a protocol consisting of 4 stages: health status assessment and provision of pre- and post-operative care during hospitalization (training), case analysis and care process planning (using the OMAHA system), post-operative evaluation and definition of additional care, home visits within 24 hours, on the 2^nd,, 6^th,, and 9^th, weeks post-discharge.	The care provided within the protocol significantly improved levels of functional autonomy in the IG compared to the CG.
Yang et al, 2022²¹21 Yang W, Xu H, Miao W, Geng Z, Geng G. Effects of transitional care based on the social support theory for older patients with osteoporotic vertebral compression fractures: A quasi-experimental trial. Australas J Ageing. 2023;42(1):185–94. Disponível em: 10.1111/ajag.13129, China English	Quasi-Experimental Study Level of Evidence: III Participants: n = 160	Investigating the effects of transitional care programs on the health of older adults with discharge and osteoporotic vertebral compression fractures.	CG: Health education before discharge and telephone follow-up after discharge. IG: Routine care and TC programs that included informational, instrumental, and emotional support. Intervention initiated before discharge and at 1, 2, 3, and 6 months post-discharge via telephone contact.	TC programs significantly improved independence in performing ADLs.

Authors Year	Thematic Categories
Authors Year	Health Education	Active involvement of older individuals and family caregivers	Multidisciplinary team involvement (*)	Post-hospital discharge follow-up
Naylor et al, 2004¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x https://doi.org/10.1111/j.1532-5415.2004... ,	a) Guidance on managing symptoms and therapy for HF and common comorbidities; b) Provision of audio recordings of educational activities.	a) Objectives aligned with the needs and preferences of the older person and/or caregivers.	a) Professionals involved: nurses, pharmacist, nutritionist, social worker, physiotherapist, cardiologist.	a) At least 8 home visits; b) Availability of telephone support. Duration: 3 months.
Courtney et al, 2012¹⁴14 Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Bradbury C, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34. Disponível em: 10.1111/j.1365-2753.2010.01547.x,	a) Exercise program training; b) Guidance on strategies for maintaining healthy behaviors.	NA	NA	a) One home visit; b) 9 telephone calls. Duration: 6 months.
Xueyu et al, 2017¹⁵15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02,	a) Guidance on managing symptoms and therapeutic approaches for HF (oral and written instruction); b) Exercise program training.	a) Requesting participants to document adherence to the protocol (exercise diary).	a) Professionals involved: nurses, physicians, pharmacists, and nutritionists.	a) 7 telephone calls. Duration: 3 months.
Carvalho et al, 2019¹⁶16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143,	a) Exercise program training (use of booklet).	a) Requesting participants to document adherence to the protocol (monthly calendar).	a) Professionals involved: nurses, kinesiologists, physiotherapists, geriatric physicians, general practitioners.	a) Weekly telephone calls. Duration: 3 months.
Geng et al, 2019¹⁷17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650,	a) Guidance on CVA management and behavioral changes for health promotion (use of booklet); b) Caregiver training on exercises and equipment usage to be performed post-discharge.	a) Objectives aligned with the needs and preferences of the older person and/or caregivers; b) Requesting caregivers to record executed healthy behaviors (diary).	a) Professionals involved: nurses, neurologist physician, rehabilitation counselor, and psychologist.	a) Weekly home visits; b) Weekly telephone calls. Duration: 3 months.
Ko et al, 2019¹⁸18 Ko Y, Lee J, Oh E, Choi M, Kim C, Sung K, et al. Older Adults With Hip Arthroplasty: An Individualized Transitional Care Program. Rehabil Nurs Off J Assoc Rehabil Nurses. 2019;44(4):203–12. Disponível em: 10.1097/rnj.0000000000000120,	a) Guidance on pain and infection control, fall prevention, and improvement of ADLs (use of booklet); b) Demonstration of exercises after THA.	a) Objectives aligned with the needs and preferences of the older person and/or caregivers and individualized interventions.	NA	NA
Kitzman et al, 2021¹⁹19 Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021;385(3):203–16. Disponível em: 10.1056/NEJMoa2026141,	NA	NA	NA	a) 3 months of outpatient sessions and 3 months of home sessions supported by telephone calls. Duration: 6 months.
Coskun, Duygulu, 2022²⁰20 Coskun S, Duygulu S. The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46–55. Disponível em: 10.1093/eurjcn/zvab005,	a) Pre- and post-operative patient training.	a) Designating a family caregiver as a member of the transition team, actively participating in the processes.	a) Professionals involved: physician, nurses, physiotherapist, nutritionist, caregiver/family member.	a) 4 home visits; b) Telephone available. Duration: 9 weeks.
Yang et al, 2022²¹21 Yang W, Xu H, Miao W, Geng Z, Geng G. Effects of transitional care based on the social support theory for older patients with osteoporotic vertebral compression fractures: A quasi-experimental trial. Australas J Ageing. 2023;42(1):185–94. Disponível em: 10.1111/ajag.13129,	a) Guidance on home self-care, rehabilitation nursing, ADLs, fall prevention, diet, and complications for patients with OVCF (use of manual).	NA	NA	a) Weekly or as-needed phone calls; b) Biweekly video calls; c) Communication via messaging app. Duration: 6 months.

[1] Correspondence Renata Farias Amorim renyamorim@yahoo.com.br

Brasil

Brasil

Interventions to promote older adult functionality in the hospital-to-home transition: an integrative review

Abstract

Objective

Method

Result

Conclusion

Brasil

Brasil

Interventions to promote older adult functionality in the hospital-to-home transition: an integrative review

Abstract

﻿Objective

Method

Result

Conclusion

Objective