1st author (year) / Country
Study design
Mean age (sd) (intervention /control) Female % (intervention / control)
Total sample size
Intervention Description Coordination measures with LTCFs Healthcare professionals involved: 1-nurse; 2-physician; 3- physiotherapist; 4-pharmacist; 5-other
Bergkvist (2009) / Sweden
Pre-Post
84 (6.2) / 84 (6.7) 71.2 / 60.3
115
Medication reconciliation done at hospital admission (pharmacist), creation of a systematic medication care plan, updated continuously (care team), patient information and education based on specially developed drug information leaflets (pharmacist), discharge summary (physician) checked by the pharmacist, reconciliation\adjustment through discussion with the physician before the patient’s discharge. Discharge summary, carefully checked and approved by both pharmacist and physician
2, 4
Boockvar (2006) / United States
Pre-Post
84.4 (8.8) / 83.9 (10.3) 78.2 / 82.7
168
Medication reconciliation on patient discharge (pharmacist) charted on a communication form and sent to the LTCF physician. The form becomes part of the LTCF pharmacy record. Communication form sent to the LTCF physician
2,4
Catic (2013) / United States Pre-Post (pilot study) 90 / 84.4 60 / 62.5
29
In-person/telephone meeting with the proxy within 24h of admission. A pocket-sized printed booklet for decision support was given to all proxies to provide standardized information. At discharge, a 1-page report summarizing the consultation focusing on recommendations for symptom control, goals of care, and advance care planning was sent to the patient’s primary care providers. Two weeks post-discharge, the proxy was telephoned for support and to review the patient’s health status, advance care planning, decision making, and proxy needs. Report sent to primary care providers
1 (palliative care nurse), 2 (geriatrician)
Crotty (2004) / Australia
Randomized controlled trial
82 / 83.4 58.9 / 63
110
On patient’s discharge, both the family physician and the community pharmacist were faxed a medication transfer summary compiled by the transition pharmacist. This communication included specific information on changes in medications that had been made in file hospital and aspects of medication management that required monitoring. The transition pharmacist also coordinated a case conference with the family physician, community pharmacist, and a registered nurse at the facility, to give information concerning medication use and appropriateness. Communication form (discharge supplemental information on medications) sent to family physician and community pharmacist, case conference
2,4
Elliott (2012) / Australia
Pre-Post
84 (median) / 84 (median) 62.8 / 58.9
428
A 7-day residential care medication administration chart (IRCMAC) was prepared (hospital pharmacist). The IRCMAC, photocopy of the discharge prescriptions and instructions for using the IRCMAC were was placed with the discharge medications and transported with the patient. The pharmacist telephoned the RCF prior to discharge to notify them that an IRCMAC would be provided. Communication form (IRCMAC) sent to the LTCF, phone call prior discharge to notify
4
Gregersen (2011) / Denmark
Non-randomized trial
88 (2 intervention groups combined) tailored group = 83% / standardized group = 68%
238
Early discharge planning and in-hospital assessments, 2 post-discharge follow-up visits (or more in the tailored group), discharge summary sent to GP. Discharge summary sent to GP
1, 2, 3
Harvey (2014) / Australia
Randomized controlled trial
83.8 (7) / 86.7 (7) 66.7 / 59.3
116
Tailored care plan development and in-hospital assessments, with possibility of additional visits as required, education and support to the LTCF staff and the GP. ”[E]ducation and support” of the GP
1 (aged care nurse), 2 (geriatrician)
Jacobs (2011) / United States
Pre-Post (quality improvement initiative)
not reported/ no control group not reported / no control group
not reported
Letter sent to the LTCF with contact information, phone contact with the LTCF facility within 2 days of discharge and review of the discharge orders, confirmation that the patient will see a doctor within 5 days. Letter sent to the LTCF, phone call
1 (heart failure nurse, RN care coordinator)
Midlov (2012) / Sweden
Pre-Post
period1: 84.4 (65-99)/ period2: 85.6 (69-102)/ period 3: 85.1 (66-95) / no control group period1: 74%/ period2: 81%/ period3: 68% / no control group
123
Patient education and LIMM discharge information form. Medication reconciliation upon admission of the patient (clinical pharmacist) and review and monitoring of medication during hospital stay according to the LIMM-model. LIMM quality control forms for discharge medication reconciliation, performed by pharmacist who gives suggestions for changes/corrections to the physician before patient discharge Medication list, general information and report written by the physician, discussed at discharge and sent to the GP Discharge form sent to the GP
2,4
Ward (2008) / United States Non-randomized trial (quality improvement initiative) 85.6 (no sd) / 78.6 (no sd) Cumulative mean age (both groups) = 83.0 (9.22) 50 / 60
20
LTCF specific communication form for discharge instructions and medication list, transmitted before discharge instead of with the patient - allowing contact with pharmacist before discharge LTCF specific communication form (so that nurses won’t have to enter it in the charts, already in the right format), transmitted before discharge instead of with the patient (so that the staff has the time to order medication before the patient’s arrival)
1,2
Zafirau (2012) / United States
Pre-Post (quality improvement initiative)
76 / 72.8 53.9 / 50
247
New standardized transfer form and education about its use. Standardized transfer form used between the acute care and the LTCF
1, 5 (LTCF staff, director of nursing)