Table 2 Transitional Care Program (TCP) Components

1. Assessment

Comprehensive assessment (may include CGA)

[18, 19, 21,22,23, 28, 30, 33, 43, 44, 50, 52]

Current/primary Clinical diagnosis/status

[20, 35, 38, 39, 45, 53, 55, 56]

Mental health

[39,40,41, 57]

Cognition and delirium

[37, 39,40,41, 57]

Medication review

[48]

Pain

[40, 41]

Nutrition

[30, 37, 40, 41]

Dental health

[57]

Elimination

[57]

Hearing and vision

[57]

Functional assessment

[37, 40, 41, 48]

Ambulation, mobility and transfer

[24, 32, 40, 41, 57]

Falls history

[37, 40, 41]

Confidence in coping and motivation

[48, 57]

Assessment of social factors and supports

[48, 57]

Review of home environment

[48, 56]

Patients’ needs and goals assessment

[28, 33, 43, 48, 50]

2. Care Planning and Monitoring

Initial care plan discussed by interdisciplinary team

[19, 28, 46, 48, 50, 52]

Weekly discussions – healthcare team members involving patients and/or family - on issues affecting participation in rehabilitation / functioning

[21, 28, 33, 37]

Weekly discussions and updates

[23, 30, 33, 38, 42, 46, 48, 50, 57]

Weekly revision of care plans

[28, 30, 33, 38, 42, 46, 48, 50, 57]

3. 1. Treatment

Continued medical care as initiated in acute care in addition to nursing, PT, SW and nutritional interventions

[18, 45]

Nursing case management

[28, 33, 36, 37, 40, 42, 46, 49, 51, 53, 56]

Acute, episodic medical care

[21, 23, 29, 33, 38, 44,45,46, 52, 53]

Specialized interventions such as respiratory therapy, enteral nutrition, IV therapy, wound care, dialysis, pain control, terminal care

[20, 21, 24, 30, 36, 38, 40, 42, 48]

Geriatric consultation

[37, 42, 46, 53, 55]

Medication reconciliation

[21, 22, 38, 55]

Mobility and rehabilitation training including transfers, stairs, strength and balance exercises and provision of mobility aids

[24, 26,27,28,29,30, 32, 33, 38, 40, 42, 45, 46, 48, 49, 52, 57]

Functional training including IADL and ADL training

[24, 29, 32, 33, 40, 46, 48, 54, 57]

Specialized rehab including SLP, hearing and dental care practitioners

[53, 54]

Psychosocial care measures such as central dining, recreational activities, group exercises, spiritual care

[23, 24, 40, 45, 46]

4. Discharge planning

Multidisciplinary discharge planning

[21,22,23,24, 28, 33, 36, 38, 39, 42, 43, 52,53,54, 56]

Collaboration with community partners

[43]

Referrals/connection with exercise and social clubs

[48]

Referrals to homecare for nursing and PT

[19]

Referrals to homecare for nursing and personal care

[29, 49, 56]

Discharge letter to FD

[22, 33]

Post discharge follow up call by a nurse/PT

[19, 56]

Post discharge follow up home visit by nurse to reinforce recommendations

[27]

5. Patient/family & staff education

Determine education needs of care partners; Coaching, health promotion/ safety involving caregivers before discharge

[24, 44, 46, 54, 56]

Staff and physician education related to care of older adults and successful delivery of the TCP

[21,22,23, 46, 54]

Tailored education to patient/family, related to specific medical conditions; surgical procedures; drug regimens; nutrition and food preparation; and physical activity

[30, 48]