https://orcid.org/0000-0002-5239-9805
Figures
Abstract
Background
Investing in transitional care programs is critical for ensuring continuity of health and coordinated care for older adults transitioning across health settings. However, literature delineating the scope of transitional care programs across Canada is limited. The aim of this systematic review of text and opinion is to characterize Canadian transitional care programs for older adults transitioning from hospital to home.
Methods
Following JBI guidelines for systematic review of text and opinion, we conducted a search of Canadian grey literature sources published online between 2016 to 2023. A 3-phase search was undertaken for: 1) Canadian databases and organizational websites; 2) advanced Google search of national sources and news media reports; and 3) advanced Google search of provincial/territorial sources. Two reviewers independently screened sources for eligibility against inclusion criteria. Data were extracted by one reviewer and verified by a second. Textual data were extracted from multiple sources to characterize each transitional care program.
Results
Grey literature search produced a total of 17,092 text and opinion sources, identifying 119 transitional care programs in Canada. Model of care was a key characteristic defining the design and delivery of transitional care programs within community (n = 42), hospital (n = 45), and facility-based (n = 32) settings. Programs were characterized by goal, population and eligibility, setting and length of program, intervention and services, and healthcare team members. Patient, caregiver, and health system outcomes were reported for 18 programs. The province of Ontario has the most transitional care programs (n = 84) and reported outcomes, followed by British Columbia (n = 10).
Conclusions
Characterizing transitional care programs is important for informing health services planning and scaling up of transitional care program models across Canada. Recognizing transitional care programs as a core health service is critical to meet the health care needs of older adults at the right time and place.
Citation: Barber BV, Gregg EE, Drake EK, Macdonald M, Hickey M, Flynn C, et al. (2024) Transitional care programs for older adults moving from hospital to home in Canada: A systematic review of text and opinion. PLoS ONE 19(7): e0307306. https://doi.org/10.1371/journal.pone.0307306
Editor: Md. Feroz Kabir, Jashore University of Science and Technology (JUST), BANGLADESH
Received: March 19, 2024; Accepted: July 2, 2024; Published: July 18, 2024
Copyright: © 2024 Barber et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its supporting information files.
Funding: The School of Nursing at Dalhousie University provided funding for JBI training that enabled the conduct of this systematic review. This work was supported by the Nova Scotia Health Research Foundation (now Research Nova Scotia) (Establishment Grant #1590) for LEW. The funding providers played no role in the design or conduct of this systematic review. There was no additional external funding received for this study.
Competing interests: All authors declare that they have no conflicts of interest and competing interests.
Introduction
The proportion of adults aged 60 and older is expected to double globally, from 12% in 2015 to 22% by 2050 [1]. This projected demographic shift presents challenges for countries to strategically prepare both health and social systems to meet the needs of the steadily aging population. The growing population of older adults in the next 20 years is particularly important for Canada, [2] due to the significant increase expected in the number of older adults 85 and over (from approximately 871,000 in 2021 to 3 million by 2050) [3]. As populations of older adults aged 85 and older experience increasingly complex health care needs, pressures on health and home care sectors will likely be exacerbated [3]. Ensuring older adults receive high quality care at the appropriate time and place is a priority for Canadian clinicians, researchers, and policy makers.
Attention to transitional care services is crucial for delivering high-quality care for older adults. Transitional care encompasses interventions designed to ensure both coordination and continuity of care as patients move between different locations or levels of care within the same location [4, 5]. Increased emphasis has been placed on the importance of improving transitions within and between health settings, [6] suggesting transitional care programs warrant recognition as a core health service. One challenge to identifying, evaluating, and synthesizing international evidence related to transitional care programs is the diverse range of terminology adopted throughout the literature. Depending on the country of origin, transitional care programs may be referred to as intermediate care models, sub-acute care, post-acute care, or alternate care units [7]. In Canada, transitional care program appears to be the predominant title, [7] and will be the term adopted for this review. For the purposes of this review, an older adult is defined as an individual 65 years or older, [8] and for Indigenous populations an older adult is defined as an individual 55 years or older [9, 10]. Indigenous populations in Canada continue to experience direct impacts of colonialism and multiple health disparities such as lower socioeconomic status, worse health outcomes, resulting in shorter life expectancy from suboptimal social, physiological and emotional support towards a healthy aging process [9, 10].
Health system challenges associated with older adults designated “alternate level of care” (ALC) in acute care hospitals is a significant contributing factor to unfavorable health outcomes and increased costs of care [11]. Older adults in hospital receive ALC status when they no longer require medical care but are not yet ready to return home or are awaiting placement in an alternate location [12]. While ALC-designated individuals wait in hospital until they can be transitioned to their final discharge destination, an acute care hospital bed remains occupied. Depending on the ALC occupancy rate within a given facility, patient flow may be significantly decreased or halted due to a lack of available hospital beds. Interruptions in patient flow contributes to overcrowded emergency departments, increased wait times, and ultimately, reduced access to essential care [11]. The resulting systemic impact of the ALC challenge on patient flow in hospitals is overwhelming and even more concerning is the subsequent effect on individual access to care.
In Canada, excluding the province of Quebec, 16% of patient days in hospital were associated with ALC status in 2022–2023 (ranging from 6.3% in Nunavut to 25.4% in Prince Edward Island) [13]. ALC patient days were highest in Atlantic provinces, with 20% in Nova Scotia and New Brunswick, 23.5% in Newfoundland and Labrador, and 25.4% in Prince Edward Island [13]. Although a significant portion of ALC designated individuals are older adults awaiting residential long-term care placement, it is important to acknowledge the ALC population with a discharge destination of home who experience a delay in discharge. The delay may be due to reasons such as time required to organize home care or other community services, essential home renovations and supports to live independently, home care capacity to admit new clients, or additional rehabilitation to improve functioning such as achieving activities of daily living [11]. Thus, while increasing available residential long-term care beds plays a critical role in addressing the ALC crisis, a more comprehensive and multi-faceted approach is required to improve older adult health care services.
Older adults that remain in hospital when acute-care treatment is no longer required often experience detrimental health effects, [14–17] including unnecessary stress for families and caregivers in relation to lack of communication and uncertainty around discharge planning [14–17]. Furthermore, a lack of resources within acute care hospitals means older adult patients are unlikely to receive the rehabilitative programming they require to improve or maintain cognitive functioning and mobility after an acute illness [14, 16, 18]. These system-level challenges suggest the infrastructure, care model, and human resources of acute care hospitals are not designed to meet the specific needs of older adults designated as ALC patients [14]. An alternative setting or program designed to meet the unique care, rehabilitative needs, and discharge goals for older adult ALC patients is ideal for promoting health and wellness of older adult populations.
There is a growing evidence base to support the role of transitional care programs for older adults moving from hospital to home. The diversity of transitional care interventions, location of program delivery, and specific program characteristics across countries is highlighted within peer-reviewed literature [19–22]. For instance, core components of transitional care programs have been found to include: assessment; care planning and monitoring; discharge planning; and patient, family, and staff education [7]. Despite core program components remaining relatively similar between countries and health care systems (i.e., Europe, U.S.A, Australia) a recent scoping review highlights the wide range of health system program delivery and intervention services [7]. Such heterogeneity makes it challenging to compare results from systematic reviews spanning diverse health care systems and transitional care models of care and intervention services.
In terms of effectiveness of transitional care programs, the majority of research has focused on health care service utilization [20, 23, 24] and cost-effectiveness [25–28]. Investigation into other patient-focused outcomes, such as improving functional status towards activities of daily living and successful discharge home are demonstrated for adults participating in facility-based transitional care programs outside hospital settings [29, 30]. However, transitional care program impact on family and caregiver outcomes such as caregiver burnout are largely unexplored [31].
The majority of research investigating transitional care programs was conducted outside Canada [7, 29, 31, 32]. Despite limited peer-reviewed literature, there is experiential knowledge Canadian transitional care programs exist [33]. Further research is needed to better understand the scope of Canadian transitional care programs, including characteristics of model of care, setting, and health care professional teams across provincial and territorial regions. In addressing this knowledge gap, we aimed to conduct a systematic review of text and opinion sources to characterize the types of transitional care programs that exist across Canada. Building the evidence base of the types and characteristics of Canadian transitional care programs (or lack thereof) can help inform provincial/territorial decision makers and health system leaders to address gaps in service delivery with greater investments in health care resources for older adults. Further, information about the scope of Canadian transitional care programs can strengthen knowledge of health system improvements internationally, such as for countries aiming to improve transitional care services for aging populations, particularly in countries with publicly funded health systems like Canada. This review was conducted following a previously published protocol [34].
Review questions
The primary aim of this systematic review of text and opinion was to identify and characterize transitional care programs that exist across Canada to support older adults with moving from hospital to home. We aimed to achieve this by answering the following research questions:
- What transitional care programs exist across Canada for older adults to support moving from hospital to home?
- What are the characteristics and reported outcomes of these programs?
Inclusion criteria
Participants.
Sources focusing on older adults transitioning from hospital-based acute care to another care setting, such as the person’s home in the community or short-term care settings (i.e., rehabilitation services in long-term care facilities and hospital settings), were considered for inclusion. This review focused on the types of transitional care programs providing care services to older adults with any medical condition, morbidity, cognition level, regardless of whether they have been in acute care previously. Sources focusing on adults younger than 65 were excluded, or 55 if the source focused on Indigenous populations.
Phenomena of interest
The phenomenon of interest was transitional care programs supporting older adults transitioning from hospital to home, including the person’s home in the community and other short-term care settings including programs operating from hospital and long-term care facilities. Characteristics of transitional care programs include services offered, types of care settings, characteristics of healthcare teams, patient populations served, integration with other healthcare services, resources and services provided for unpaid caregivers, and the impact of the program. Terminology used to describe transitional care programs and related interventions are inconsistent across regions and care settings in Canada [33]. Interchangeable terms identified in the literature on transitional care programs were included in this review such as, “intermediate care programs,” “reintegration programs,” “subacute care,” “reactivation programs,” “short-term transitional care programs,” “skilled nursing facilities,” and “post-acute care.” Transitional care interventions and programs focused on transitioning seniors to long-term residential care facilities were excluded from this review. Care programs providing short-term respite and observation stays were also excluded.
Context
The focus of this review was on Canadian transitional care programs delivered by provincial/territorial health systems and services. Canada consists of 10 provinces and 3 territories with diverse geographic characteristics (e.g., urban vs. rural), local cultural/subcultural contexts, and varying sociodemographic factors (e.g., race, age, ethnicity, language, gender identities). Sources focusing on transitional care programs outside of Canada were excluded.
Methods
This systematic review was conducted in accordance with JBI methodology for systematic reviews of text and opinion, [35] and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist for systematic reviews [36] (S1 Appendix). Ethics approval was not required for this systematic review because all data sources are secondary and already in the public domain.
Search strategy
A list of Canadian sources of grey literature and a comprehensive search strategy was developed by team members in conjunction with two health science librarians (S2 Appendix). A 3-phase search strategy was undertaken by two researchers independently. First, an initial limited search of Canadian grey literature databases and organizational websites was conducted to identify sources on the topic of transitional care programs. Canadian databases and organizational websites of grey literature included Government and Legislative Libraries Online Publication Portal (GALLOP), Canadian Institute for Health Information (CIHI), Canadian Nurses Association, Theses Canada Portal, Google Programmable Search Engine for Canadian Federal Documents, and Canadian Agency for Drug and Technologies in Health (CADTH). Next, an advanced incognito Google search of Canadian resources and Canadian news media reports from ProQuest and Nexis Uni was conducted. Lastly, an advanced Google search of all 10 provinces and 3 territories using provincial/territorial search term was completed to retrieve information about local transitional care programs, including local pilot projects, health region-specific programs and provincial/territorial organizations. A list of keywords and index terms are provided (S2 Appendix). A forward search of identified transitional care programs was conducted to gather additional text and opinion sources that our search may have missed.
All grey literature sources published since 2016 were included in this review. In 2016, the World Health Organization introduced a framework on Integrated, People-centred Health Services during the Sixty-Ninth World Health Assembly [6]. This framework identified coordination of services within and across sectors as a key strategy for enhancing health systems, particularly during care transitions. Since this framework was introduced, there has been an increase in efforts to improve health outcomes and experiences of people transitioning across health settings. Grey literature sources published in English or French were considered for inclusion, as Canada’s co-official languages. Sources published in French and unavailable online in English were translated by team members with French-language skills. The initial search was conducted from July to October 2022, and updated from October to November 2023 to verify source links and identify new eligible programs; no additional transitional care programs were located.
Study selection
At the time the search was conducted, all potential sources were screened against inclusion criteria. Most grey literature sources did not have an abstract for screening, except sources within the Theses Canada Portal. Therefore, titles and abbreviated descriptions were used to screen sources by two independent reviewers (BB and EKD) for assessment against inclusion criteria using a screening tool (S3 Appendix). Identified sources from each search were imported to Zotero and duplicates removed. Sources sought for retrieval were uploaded to Covidence, [37] to facilitate full-text review. Any conflicts that arose between reviewers were resolved through discussion. Multiple sources (i.e., websites, news media, reports) related to each transitional care program were included in the final review and assessed to gather as much information as possible about each transitional care program. The results of the search and included sources are presented in the PRISMA flow diagram Fig 1. Full-text sources that did not meet inclusion criteria were excluded, with reasons for exclusion provided (Fig 1).
From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/.
Assessment of methodological quality
Grey literature sources selected for inclusion were assessed by two independent reviewers (BB and EG) using the JBI critical appraisal checklist (2020) for text and opinion [35]. Results of the critical appraisal are reported in Table 1. Sources were not excluded based on their quality. During critical appraisal, reviewers identified questions 4, 5, and 6 were unsuitable for text and opinion sources included in this review (Question 4: Is the stated position the result of an analytical process and is there logic in the opinion expressed? Question 5: Is there reference to the extant literature? and Question 6: Is any incongruence with the literature/sources logically defended?). Grey literature sources could not be assessed for logic in opinion expressed, were not reporting on empirical research involving reference to extant literature, and sources did not report any incongruence with literature sources. Furthermore, reviewers considered all organizations delivering transitional care programs for older adults to have standing in the field (Question 2: Does the source of opinion have standing in the field of expertise).
Data extraction
Textual data were extracted from sources included in the review by 6 independent reviewers (BB, EG, CF, MH, EMc, and SMG) using a modified version of the standardized JBI data extraction tool (S4 Appendix). Two reviewers (BB and EG) pilot-tested the extraction tool with 6 sources, to identify any discrepancies and ensure consistency of data extraction. Extracted data were verified by a second reviewer (BB, EG, EM, MM, and LEW). Conflicts between reviewers regarding data extracted were resolved through discussion or by a third reviewer. Textual data were extracted verbatim from each source, including direct quotes of patient testimonials and transitional care program effectiveness. Unique to this systematic review of text and opinion was the inclusion of multiple sources of webpage links and reports to characterize one transitional care program (S5 Appendix). Textual data were extracted from multiple sources to gather as much information about each transitional care program goal, population or eligibility, setting and length of program, intervention and services offered, and healthcare team members.
Data synthesis and presentation of results
Findings from textual sources are presented in narrative format to depict characteristics and outcomes of transitional care programs. Textual sources were not graded using the JBI ConQual approach [38] for dependability and credibility of qualitative findings. The ConQual approach is aligned to meta-aggregation in qualitative systematic reviews and does not have formal guidance for use within text and opinion systematic reviews [39]. The omission of a ConQual score is a deviation from the protocol. Textual data are presented in tabular form with a narrative summary to describe how findings address the review’s questions and objectives.
Results
This 3-phase grey literature search produced a total of 17,092 text and opinion sources, resulting in the identification of 119 transitional care programs in Canada published from 2017 to 2023. Sources include websites, reports, and news articles. We screened 10,117 sources in Zotero where 1,726 sources were sought for retrieval. After screening in Zotero, 1,089 sources were exported to Covidence for full-text review. A total of 271 sources of text and opinion were included in this review (S5 Appendix). See Fig 1. for the PRISMA flow chart.
Characteristics of Canadian transitional care programs
Model of care was a key characteristic defining the design and delivery of transitional care programs. Three models of care including community, hospital, and facility-based characterize the setting where transitional care programs are delivered in Canada. For example, community-based transitional care programs are delivered within older adults’ home or in temporary apartments. Hospital-based transitional care programs are delivered on designated transitional or rehabilitation units that are designed to support patients’ needs as they prepare to transition out of hospital. Facility-based transitional care programs are delivered in a facility separate from acute care hospitals, such as rehabilitation centers and reactivation centres, or within leased units at long-term care or assisted-living facilities. A total of 42 community, 45 hospital, and 32 facility-based transitional care programs were identified. Differences between provincial/territorial regions including total population and proportion of older adults is important for contextualizing the number of transitional care programs identified. A summary of provincial/territorial population demographics and number of transitional care programs by model of care are presented (Table 2).
Characteristics defining hospital and facility-based transitional care programs were homogenous however, characteristics of community-based transitional care programs were heterogenous. A summary of characteristics for 119 transitional care programs are presented in Table 3. Transitional care programs are categorized based on province and characterized by program name, program goal, population and eligibility, setting and length of program, intervention and services, and healthcare team members. Additional characteristics of transitional care programs such as funding models, involvement of unpaid caregivers, discharge process, and integration with other health services were not included due to unavailable or unclear data for almost all transitional care programs.
Community transitional care programs provide tailored services, goal-oriented patient-centred care, coordination of care, rehabilitation for older adults, and short-term services ensuring older adults transition safely home. Community transitional care programs provide services to older adults who are medically stable and require additional support to return home. To be eligible for transitional care, older adults are in-hospital and recovering from acute illness, surgical procedure, or complex chronic conditions. Community transitional care programs are delivered within older adults’ home or temporary apartment units. Program length is short-term, between 3 to 4 months, up to a maximum of 6-months. Services include 24/7 clinical care and case management, hospital discharge planning, support with activities of daily living, rehabilitation therapy, meal preparation, housekeeping, transportation to appointments, medication administration, assistive medical devices and equipment, referrals to community supports, and self-management training. Healthcare team members include, but are not limited to, specialized nursing health professionals, care coordinators, rehabilitation therapists (i.e., physiotherapy, occupational, massage), personal support workers, social workers, and dieticians.
Hospital transitional care programs provide services for older adults that are being discharged from hospital, medically stable, and requiring additional support to improve functional and cognitive functioning before returning home. The goal of hospital transitional care programs is to facilitate timely and safe discharges, avoid hospital re-admission, and return older adults to highest level of mental and social functioning through restorative care. Hospital program services provide individualized and specialized 24/7 nursing care to support older adults with activities of daily living, rehabilitation, and routine medical needs. Hospital program length is short-term between 2 to 6 weeks. Healthcare team members include nurses, care coordinators, physiotherapist, occupational therapists, recreational therapists, and dieticians.
Facility-based transitional care programs provide enhanced health services for older adults that no longer need hospital care but require additional support to maintain health status and quality of life before transitioning home. Facility-based programs provide individualized assessment and care planning, 24/7 care for activities of daily living, medication management, recreation and social programs. Designated units with private rooms in long-term care homes or assisted living facilities provide transitional care services between 4 to 12 weeks. Healthcare team members include personal support workers, therapists, and nurses.
Reported outcomes.
Eighteen transitional care programs reported qualitative and quantitative patient, caregiver, and health system outcomes (Table 4). Outcomes were reported from Ontario (n = 14, Community = 5, Hospital = 5, Facility = 4), British Columbia (n = 2, Hospital = 1 and Facility = 1), New Brunswick (Community = 1), and Prince Edward Island (Community = 1). Patient, caregiver, and health system leader testimonials describe the impact of transitional care programs for improving quality of care, coordinating services, reducing caregiver stress for families, and enhancing rehabilitation and health outcomes for patients. The impact for one older adult patient is described as, “Without the help of my care navigator, I would have ended up in a group home, and I’m not ready for that yet. It would have been extremely difficult to make this happen on my own” [71]. Health system outcomes are reported as quality improvement initiatives for improving patient reported outcomes, coordination of care, and reducing health system costs associated with emergency department visits, hospital readmission, and extended length of stay. The COACH program in Prince Edward Island reports primary care visits decreased by 50% per month, emergency department visits decreased by 33% per month, and $1.41 million (CAD) in health system costs were reduced from 13 clients and families [155].
Discussion
This systematic review of text and opinion characterizes transitional care programs that exist across Canada for older adults to transition from hospital to home. Our grey literature search identified 119 transitional care programs, differentiated by model of care in community (n = 42), hospital (n = 45), and facility-based (n = 32) settings. Most transitional care programs we identified exist in Ontario (n = 84), British Columbia (n = 10), Manitoba (n = 7), and Alberta (n = 5). Ontario has developed the most expansive range of transitional care programs in community (n = 31), hospital (n = 30), and facility-based (n = 23) settings. Of 18 transitional care program reported outcomes, 14 were reported from Ontario and show improved health outcomes and reduced health system costs from fewer emergency visits, hospital readmissions and extended length of stay. Characteristics and reported outcomes of transitional care programs are important for informing health services planning and scaling up of transitional care program models of care across Canada.
Investing in transitional care programs across provincial/territorial regions is particularly important for growing populations of older adults. Canada’s population of older adults is expected to more than double in the next 20 years [2]. An increasing older adult population has many implications in terms of ensuring adequate supports are in place to provide home care services, suitable housing, transportation, and financial resources for rising costs of living. That there are limited examples of transitional care programs in Canada is concerning, particularly for provinces and territories with above average proportions of older adult populations (Table 2). Atlantic provinces (i.e., Nova Scotia, Newfoundland and Labrador, Prince Edward Island), and Quebec have the fewest number of transitional care programs however, experience above average proportions of people aged 65 and older and can anticipate significant increases in the proportion of older adults aged 85 and older over the coming decades [3]. Ontario, British Columbia, Manitoba, and Alberta have five or more transitional care programs, making them better equipped to scale up existing transitional care programs across the province to meet the needs of an aging population. Whereas provinces with few or no transitional care programs require immediate action to plan for implementing transitional care programs.
Transitional care programs provide a means of addressing complex health system challenges facing older adults and contribute towards achieving the quintuple aim of healthcare improvement [160]. The quintuple aim of healthcare aims to address health equity; population health outcomes; clinician well-being; patient experience; and reduce healthcare costs [160, 161]. Reported transitional care program outcomes show improved older adult experience, health outcomes, access to equitable care, clinician and caregiver well-being, and significant reductions in acute care costs associated with emergency visits, extended stays, delayed discharge, and hospital readmission [7, 19, 20]. A systematic review of transitional care programs within long-term care facilities show long-term care transitional care programs improve outcomes with a greater percentage of older adults returning home [29]. These findings are consistent with a scoping review of transitional care programs for trauma patients across the United States [32]. A total of 10 studies describing 9 transitional care programs show readmissions were reduced by 5%, emergency visits reduced by 13%, and follow-up adherence improved by 75% [32].Transitional care programs not only improve quality of care and health outcomes, they also reduce healthcare disparities and inequities attributed to older adults’ lower socioeconomic condition and poor coordination of care during transitions between health settings [162–164]. Interprofessional transitional care teams are well positioned to identify and address inequitable access to healthcare for older adults by assessing individual health needs within community and home settings, such as access to transportation, nutritious food, and resources required to maintain a safe and supportive housing environment. Recognizing the impact of transitional care programs in relation to the quintuple aim for health care [160] could strengthen evidence for investing in transitional care programs as a core health service.
Limited peer reviewed literature exists in Canada identifying transitional care programs. We conducted a grey literature search to fill this knowledge gap, of which the 119 transitional care programs we identified would not have been produced from a search of academic literature. Limited academic literature and large volumes of grey literature makes it challenging for health system decision-makers to find and use best available evidence to respond to urgent and emerging health system crisis, such as the influx of older adults designated with ALC status and long waitlists for long-term care [11]. There is an increasing need to include different sources of evidence, such as grey literature, so that systematic and rapid reviews comprise the most up-to-date information about health system interventions [165]. These findings can inform health system leaders with design and delivery of future transitional care programs, such as tailoring existing transitional care program goals, services, length of program, and healthcare team members. Furthermore, examples of transitional care programs across Canada are particularly important for rapid-cycle improvement and implementation of health services across diverse provincial/territorial governing health authorities. Results from this systematic review are also relevant to other countries with similar nationally funded and regionally governed health care systems (e.g., Australia, New Zealand).
Further research is needed to build the evidence base of how transitional care programs are implemented and operationalized in provincial/territorial health systems. For example, interviews with transitional care program leaders and managers would contribute in-depth understanding of lessons learned and challenges and enablers for implementing transitional care programs. This information would benefit health system leaders with tailoring transitional care program design and model of care based on available health system resources (i.e., financial, health human resources, integration with other health services) and urban and rural context. We recommend future research gather more in-depth information about strategies for implementing and funding transitional care programs with health system leaders and transitional care program managers. Furthermore, exploring patient experience and healthcare outcomes would improve the design of patient-centered transitional care programs across different community settings. Most transitional care programs identified in this review were within urban settings, as such we recommend future research investigate model of care and services best suited to meet patient needs within rural communities. Improving uptake of rural transitional care programs is particularly important for addressing health inequities for older adults with limited access to healthcare services, inadequate housing, and risk of extended length of stay in hospital [166].
Limitations
Findings from this systematic review of text and opinion should be considered in the context of potential methodological limitations. First, our search of grey literature was limited to textual sources and data available online. Due to the high volume of different grey literature sources, we focused on textual sources of grey literature and were unable to include video and audio content. Findings are also limited to data available online by transitional care programs. It was not possible to include additional characteristics of transitional care programs that were of interest such as funding models, program status (i.e., active, in-active, pilot), involvement of unpaid caregivers, discharge process, and integration with other health services due to the fact these data were unavailable or unclear for almost all transitional care programs we identified. Furthermore, due to the high number of transitional care programs identified (n = 119), it was unfeasible to contact each program to verify accuracy and availability of information online. Second, this systematic review of grey literature aimed to characterize the scope of Canadian transitional care programs. Therefore, we did not hand search a comprehensive list of hospitals and long-term care facilities where transitional care programs could exist. It is likely there are additional transitional care programs that were not identified in this review. Lastly, we found many of the questions for assessing methodological quality using the JBI critical appraisal checklist tool [35] were not suitable for the text and opinion sources included in this review (i.e., health centre websites). We recommend that the methodological guidelines for conducting systematic reviews of grey literature be updated to include methodological quality tools relevant to the wide range of text and opinion sources available online.
Conclusion
A growing body of evidence demonstrates the impact of transitional care programs for improving health and well-being of older adults transitioning from hospital to home. This systematic review maps and characterizes the scope of transitional care programs across Canada, contributing to the evidence base and highlighting provincial/territorial regions requiring greater investment to support increasing populations of older adults. Characterizing transitional care programs is important for informing health services planning and scaling of transitional care programs across Canada. Findings from this systematic review are relevant for other countries aiming to understand the scope of transitional care services and characteristics of these programs that could improve existing health care services for older adult populations. Investments are required to recognize transitional care programs as a core health service that is needed to meet the health care needs of older adults and addressing the quintuple aim of health care. Further research is needed to build an evidence base of processes for operationalizing and implementing transitional care models across different communities specific to the needs of older adult populations, health human resources, and integration with other health services.
Acknowledgments
The authors would like to acknowledge the Aligning Health Needs and Evidence for Transformative Change: A JBI Centre of Excellence, Dalhousie University School of Nursing for delivering JBI training that enabled the conduct of this review.
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