Navigation Support during Transitions in Care for Persons with Complex Care Needs: A Systematic Review
Abstract
:1. Introduction
2. Methods
2.1. Role and Involvement of the Expert Panel
2.2. Search Strategy
2.3. Inclusion/Exclusion Criteria and Study Selection
2.4. Data Extraction and Quality Appraisal
2.5. Data Synthesis
2.6. Ethics
3. Results
3.1. Study Selection
3.2. Study Characteristics
3.3. Certainty of Evidence across Outcomes
3.4. Outcomes
3.4.1. Patient Quality of Life
Authors, Year | Study Design | Country | No. of Participants | Intervention | Control | Outcomes of Interest |
---|---|---|---|---|---|---|
Balaban et al., 2017 [11] | RCT | USA | Intervention n = 747 Control n = 1190 | For 30 days following discharge from hospital to home or a skilled nursing facility, patient navigators provided support to persons at high risk of readmission. Navigators first met with patients in hospital to assess post-discharge needs, then connected weekly by telephone. Navigators addressed barriers to medication management, arranged transportation, made connections to unspecified services, communicated with primary care providers, assisted with coordinating health insurance, and supported patient self-management. | In the control group, usual inpatient, transitional, and outpatient care was provided. | ED visits (within 30 days of a transition in care), follow-up with a health or social service provider, readmission rates (within 30 days of a transition in care). |
Carter et al., 2021 [16] | RCT | USA | Intervention n = 288 Control n = 285 | Community health workers supported persons at high risk for readmission transitioning from hospital to home or a short-stay rehabilitation unit for 30 days post-discharge by connecting by phone, text message, and visiting in person. They provided health coaching, arranged clinical services, and provided motivational interviewing and psychosocial support. Usual care was also provided to the intervention group. | In the control group, participants received usual post-discharge care, which included outpatient referrals. | ED visits (within 30 days of a transition in care), follow-up with a health or social service provider, readmission rates within 30 days of a transition in care) |
Coller et al., 2018 [15] | RCT | USA | Intervention n = 77 Control n = 70 | As a component of the Plans for Action and Care Transitions intervention, caregivers of children with medical complexity received support from a transition coach during the transition from hospital to home. Transition coaches met with patients before discharge, conducted home visits, and connected with families by phone 3 times within 30 days post-discharge. Transition coaches elicited caregiver goals, provided coaching, and reviewed medication self-management, follow-up appointments, and “red flags” that could lead to rehospitalization. | In the control group, participants received usual care which consisted of care planning, case management, and communication with community services. | Readmission rates (within 30 days of a transition in care) |
Johnson et al., 2018 [39] | RCT | UK | Intervention n = 221 Control n = 220 | Participants discharged from mental health crisis resolution teams received ten one-hour sessions over four months from a peer support worker. The peer support worker helped them complete a personal recovery workbook that involved creating goals, making plans to re-establish a support network, identifying early warning signs, and creating a plan to avoid relapse. | Control group participants received the recovery workbook by mail and were encouraged to complete it independently. Both intervention and control groups also received usual care. | Patient satisfaction |
Kidd et al., 2016 [42] | Single-arm study | Canada | Intervention n = 31 | The “welcome basket” intervention consisted of peer support workers providing weekly one-on-one support to persons with severe mental illness for four weeks following discharge from a psychiatric hospital. Peer support workers provided patients with a “welcome basket” of needed items and helped familiarize the person with community resources and supports to facilitate self-management. The vector of communication was not specified. | There was no control group. Results were compared pre- and post-intervention. | Patient QOL |
LaBedz et al., 2022 [38] | RCT | USA | Intervention n = 518 Control n = 511 | In the PArTNER study, hospitalized patients with pneumonia, heart failure, myocardial infarction, sickle cell disease, and chronic obstructive pulmonary disease received support from community health workers and peer coaches for 60 days post-discharge. Within hospital and after discharge, these providers addressed barriers to care, taught self-management skills, and used a personalized discharge tool to review follow-up visits, medications, tests, and lifestyle changes. | In the control group, participants received usual care from their medical team. | Follow-up with a health or social service provider |
Mitchell et al., 2022 [35] | RCT | USA | Intervention n = 353 Control n = 356 | The re-engineered discharge for depression intervention was delivered to participants with moderate to severe depression transitioning from hospital to home. Participants received up to 12-weeks of post-discharge telehealth support from a counselor, which included cognitive behavioral therapy, self-management support, and patient navigation. Patient navigation involved arranging transportation, scheduling appointments, and relaying information to primary care providers. | In the control group, participants received a post-discharge telephone call from a discharge educator, who reviewed medication, confirmed follow-up appointments, and provided education about symptoms and the plan of care. | ED visits (within 30 days of a transition in care), readmission rates (within 30 days of a transition in care) |
Ng & Wong, 2018 [34] | RCT | Hong Kong, China | Intervention n = 41 Control n = 43 | In the home-based palliative heart failure program, persons with end-stage heart failure received home visits and phone calls from a palliative nurse case manager over a 12-week period after transitioning from hospital to home, in addition to usual care. The nurse case manager assessed symptoms, provided spiritual and social support, discussed goals and treatment preferences, and made referrals to other providers and services when necessary. | The control group participants received usual care and two social calls. Usual care involved a pre-discharge palliative care referral, standard discharge planning, and an outpatient palliative care clinic appointment. | Patient QOL, patient satisfaction |
Pang et al., 2023 [40] | Cohort study | Australia | Intervention n = 63 Control n = 262 | Persons at high risk of hospital readmission received targeted care coordination, which involved weekly phone calls for 30 days post-discharge by a registered nurse, who coordinated and addressed barriers to attending follow-up appointments. To promote continuity, the nurse also relayed information to general practitioners. | In the comparison group, usual care was provided, which included follow-up appointments with the treating ward team. Persons booked their own appointments or had appointment instructions mailed to them. | Follow-up with a health or social service provider |
Reeves et al., 2019 [33] | 3-group RCT * | USA | Intervention n = 88 Control n = 87 | During the Michigan Stroke Transition Trial, stroke patients transitioning from hospital to home or a rehabilitation facility received case management support from a social worker which included a biopsychosocial assessment, development of a care plan based on patient goals, assistance arranging appointments and community service referrals, and practical and emotional support. Support was provided through home visits and phone calls for approximately 60 days after returning home from hospital. | In the control group, usual care consisted of providing standard post-discharge instructions about medications, follow-up appointments, and referrals. | Patient QOL |
Rose et al., 2018 [32] | RCT | Canada | Intervention n = 236 Control n = 234 | In addition to usual care, patients in the intervention group with chronic obstructive pulmonary disease received support from a case manager for one year after discharge home from hospital. The case manager provided education and individualized action plans, telephone consultations, and motivational interviewing focused on self-management. They also relayed information to family doctors and hospital specialists. | Usual care consisted of three monthly outpatient clinic visits, an eight-week rehabilitation program, and an individualized action plan that included education materials. | Patient QOL, patient satisfaction |
Samuels et al., 2021 [12] | Single-arm study ** | USA | Intervention n = 49 Control n = 51 | Patient navigators provided 12 months of support to frequent ED users after discharge from the ED. Patient navigators scheduled and reminded persons about medical appointments, and accompanied patients to appointments if necessary. They routinely contacted patients by phone to assess needs and address barriers to care, and made referrals as required. | Standard care was provided to the control group. | Patient satisfaction |
Scanlan et al., 2017 [14] | Single-arm study | Australia | Intervention n = 64 | Following discharge from an inpatient psychiatric unit, patients received six to eight weeks of support from a peer worker who had their own lived experience of mental illness and recovery. Supports were tailored to each person but were mostly focused on providing emotional and practical support and connections to community resources. | There was no control group. | Patient satisfaction |
Seaberg et al., 2017 [37] | RCT | USA | Intervention n = 148 Control n = 134 | Patient navigators provided support to persons who had five or more ED visits within 12 months. During the initial ED visit, any subsequent visits, and by phone at 2 weeks and 12 months, navigators reviewed the patients’ diagnoses and care plans, arranged follow-up appointments and transportation, and linked patients with community resources. | Standard care was provided to the control group. | Follow-up with a health or social service provider, patient satisfaction |
Taylor et al., 2022 [36] | RCT | USA | Intervention n = 349 Control n = 342 | In the sepsis transition and recovery program, persons with sepsis at high risk of readmission received usual care plus telephone support from a sepsis nurse navigator for 30 days post-discharge. The navigator promoted care planning and self-management, coordinated follow-up care, assessed and treated health concerns, and escalated care when needed. | The control group received usual care at discharge which often included patient education, follow-up instructions at discharge, and referrals for home care services. | ED visits (within 30 days of a transition in care), follow-up with a health or social service provider, readmission rates (within 30 days of a transition in care) |
Thompson et al., 2018 [41] | Cohort study | USA | Intervention n = 159 Control n = 280 | Community navigators supported super utilizers (people with 11 or more hospital encounters in one year following an ED encounter or hospital admission). For one year, navigators connected clients with community resources, addressed barriers to care, tailored health information to client needs, and encouraged clients to adopt healthy behaviors. | The comparison group consisted of data from super utilizers from neighboring zip codes who did not receive the intervention. | Readmission rates (within 30 days of a transition in care) |
Xiang et al., 2019 [13] | Single-arm study | USA | Intervention n = 586 | The bridge model for super utilizers is a social work-based transitional care intervention, implemented to address the medical and social needs of super utilizers (persons with ≥5 hospital admissions over 12 months), over a 6–12-month period. The social worker assessed needs, coordinated care, provided counseling, and organized services and referrals. | There was no control group, and results were compared pre- and post-intervention. | Readmission rates (within 30 days of a transition in care) |
Patient Quality of Life | Emergency Department Visits (Within 30 Days of a Transition in Care) | Follow-Up Visit with a Health or Social Service Provider | Patient Satisfaction | Readmission Rates (Within 30 Days of a Transition in Care) | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Study Design | RCT | Single-Arm Study | RCT | RCT | Cohort Study | RCT | Single-Arm Study | RCT | Cohort Study | Single-Arm Study |
No. of studies | 3 | 1 | 4 | 5 | 1 | 4 | 2 | 5 | 1 | 1 |
Risk of bias | −1 | −1.5 | −1 | −2 | −1 | −1.5 | −2 | −1.5 | −1.5 | −1.5 |
Inconsistency | −0.5 | 0 | 0 | −1 | 0 | −2 | −0.5 | −1.5 | 0 | 0 |
Indirectness | −0.5 | −0.5 | −0.5 | −0.5 | −0.5 | −0.5 | −0.5 | −0.5 | −0.5 | −0.5 |
Imprecision | −0.5 | −2 | 0 | 0 | −1.5 | 0 | −2 | 0 | −0.5 | 1 |
Publication bias | Undetected | Undetected | Undetected | Undetected | Undetected | Undetected | Undetected | Undetected | Undetected | Undetected |
Certainty of evidence | Very low ⨁◯◯◯ | Very low ⨁◯◯◯ | Low ⨁⨁◯◯ | Very low ⨁◯◯◯ | Very low ⨁◯◯◯ | Very low ⨁◯◯◯ | Very low ⨁◯◯◯ | Very low ⨁◯◯◯ | Very low ⨁◯◯◯ | Very low ⨁◯◯◯ |
Overall certainty of evidence across outcomes: Very low ⨁◯◯◯ |
3.4.2. Emergency Department Visits (Within 30 Days of a Transition in Care)
3.4.3. Follow-Up Visit with a Health or Social Service Provider
3.4.4. Patient Satisfaction
3.4.5. Readmission Rates (Within 30 Days of a Transition in Care)
3.4.6. Intervention Duration and Prioritized Outcomes
4. Discussion
4.1. Future Research
4.2. Limitations
4.3. Development of a Best Practice Guideline
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Certainty of Evidence | Definition |
---|---|
High ⨁⨁⨁⨁ | We are very confident that the true effect lies close to that of the estimate of the effect. |
Moderate ⨁⨁⨁◯ | We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. |
Low ⨁⨁◯◯ | Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. |
Very Low ⨁◯◯◯ | We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect. |
GRADE Criteria | Definition |
---|---|
Risk of bias | Limitations in the study design and execution that may bias study results. Valid and reliable quality appraisal tools are used to assess the risk of bias. |
Inconsistency | Unexplained differences (heterogeneity) of results across studies. Inconsistency is assessed by exploring the magnitude of difference and possible explanations in the direction and size of effects reported across studies for a defined outcome. |
Indirectness | Variability between the research and review question. There are four sources of indirectness that are assessed: differences in population, interventions, outcomes measured, and comparators. |
Imprecision | The degree of uncertainty around the estimate of effect. This is usually related to sample size and number of events. Studies are examined for sample size, number of events, and confidence intervals. |
Publication bias | Selective publication of studies based on study results. If publication bias is strongly suspected, downgrading is considered. |
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Share and Cite
Howitt, L.; Jacob, G.; Zucal, G.; Smith, J.; Crocker Ellacott, R.; Sharkey, S. Navigation Support during Transitions in Care for Persons with Complex Care Needs: A Systematic Review. Healthcare 2024, 12, 1814. https://doi.org/10.3390/healthcare12181814
Howitt L, Jacob G, Zucal G, Smith J, Crocker Ellacott R, Sharkey S. Navigation Support during Transitions in Care for Persons with Complex Care Needs: A Systematic Review. Healthcare. 2024; 12(18):1814. https://doi.org/10.3390/healthcare12181814
Chicago/Turabian StyleHowitt, Lyndsay, Greeshma Jacob, Giulia Zucal, Judy Smith, Rhonda Crocker Ellacott, and Shirlee Sharkey. 2024. "Navigation Support during Transitions in Care for Persons with Complex Care Needs: A Systematic Review" Healthcare 12, no. 18: 1814. https://doi.org/10.3390/healthcare12181814