Transitional care interventions: Relevance for nursing in the community

Alice Coffey, Helen Mulcahy, Eileen Savage, Serena Fitzgerald, Colin Bradley, Lazelle Benefield, Patricia Leahy‐Warren

The coordination and integration of health care is compromised by complex challenges related to transitions between care settings, greater prevalence of chronic health conditions, and older individuals with increasing levels of dependency. Transitional care incorporates a broad range of services designed to provide care continuity. This systematic review aims to synthesize and present findings regarding the relevance of transitional care interventions to community nursing. A systematic search of electronic databases was conducted as part of a larger review to identify evidence-based interventions to support a model to guide nursing and midwifery in the community in Ireland. All relevant empirical studies published in English between 2010 and 2015 were included. Studies were assessed based on inclusion criteria. The Cochrane Risk of Bias and AMSTAR tools were used to assess the methodological quality of studies. Key themes and concepts were extracted and synthesized. Transitional care interventions had significant positive effects in reducing all-cause readmissions, mortality, and heart failure-related rehospitalizations. Effective transitional care requires excellent communication between acute and primary care providers. This has implications for integration and organization of care across settings and nursing competence.