Interventions to improve transitional care between nursing homes and hospitals: a systematic review

J Am Geriatr Soc. 2010 Apr;58(4):777-82. doi: 10.1111/j.1532-5415.2010.02776.x.


Transitions between healthcare settings are associated with errors in communication of information and treatment plans for frail older patients, but strategies to improve transitional care are lacking. A systematic review was conducted to identify and evaluate interventions to improve communication of accurate and appropriate medication lists and advance directives for elderly patients who transition between nursing homes and hospitals. MEDLINE, ISI Web, and EBSCO Host (from inception to June 2008) were searched for original, English-language research articles reporting interventions to improve communication of medication lists and advance directives. Five studies ultimately met all inclusion criteria. Two described interventions that enhanced transmission of advance directives, two described interventions that improved communication of medication lists, and one intervention addressed both goals. One study was a randomized controlled trial, whereas the remaining studies used historical or no controls. Study results indicate that a standardized patient transfer form may assist with the communication of advance directives and medication lists and that pharmacist-led review of medication lists may help identify omitted or indicated medications on transfer. Although preliminary evidence supports adoption of these methods to improve transitions between nursing home and hospital, further research is needed to define target populations and outcomes measures for high-quality transitional care.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Advance Directives
  • Aged
  • Checklist
  • Communication Barriers
  • Continuity of Patient Care / organization & administration*
  • Drug Therapy
  • Evidence-Based Practice
  • Frail Elderly
  • Hospitals*
  • Humans
  • Medical Errors / prevention & control
  • Nursing Homes / organization & administration*
  • Patient Discharge
  • Patient Transfer / organization & administration*
  • Patient-Centered Care
  • Research Design
  • Total Quality Management / organization & administration*