Table 1 Study characteristics (n = 10), interventions, outcomes assessed and main results

Adekpedjou, 2020, Canada [19]

Shared decision-making on housing arrangements through caregiver training and supportive decision guide

Cluster Randomized Trial

Informal caregivers of cognitively impaired older people

Intv n = 138 (median = 60)

Contr n = 158 (median = 63)

Primary: Proportion of caregivers self-reporting an active role in decision-making.

Secondary: Preferred health-related housing option, decision made, decisional conflict, decision regret, and burden of care as perceived by caregivers.

• Non-significant intervention effect on self-reported active informal caregiver role in decision-making (79.6% in intv group vs 68.4% in contr group; 95% CI for 12% difference between groups − 2 to 27%; P = 0.10).

• No difference between the intervention group and control for preferred option (% stay home) (50.7% vs 51.9%; p = 0.95). No difference between the intervention group and control for actual decision (% stay home) (19.6% vs 16.4%; p = 0.60).

• No difference between the intervention group and control for decision regret (52.9% vs 48.7%; p = 0.60).

• No difference between the intervention group and control for match between preferred option and actual decision (64.5% vs 58.2%; p = 0.28).

• No difference between intervention group and control for decisional conflict and caregivers’ burden (mean of 29.10 vs 30.48; p = 0.62).

Coleman 2006, USA [20]

Hospital discharge preparation tool + support of a transition coach

Randomized controlled trial

Older people facing hospital discharge

Intv n = 379 (mean = 76)

Contr n = 371 (mean = 76)

Primary: Unplanned re-hospitalizations within 30, 90 and 180 days

Secondary: Unplanned re-hospitalizations at 30, 60, and 90 days post-discharge for the same condition

• Fewer re-hospitalizations in the intervention group as compared to control within 30 days (8.3% vs 11.9%; OR = 0.59; 95% CI 0.35–1.00) and 90 days (16.7% vs 22.5%; OR = 0.64; 95% CI 0.42–0.99); no difference at 180 days (25.6% vs 30.7%; OR = 0.80; 95% CI 0.54–1.19).

• Fewer re-hospitalizations for the same condition in the intervention group as compared to control within 90 days (5.3% vs 9.8%; OR = 0.50; 95% CI 0.26–0.96) and 180 days (8.6% vs 13.9%; OR = 0.55; 95% CI 0.30–0.99); no significant difference between study groups at 30 days (2.8% vs 4.6%; OR = 0.56 95% CI 0.24–1.31).

Coleman, 2004, USA [21]

Hospital discharge preparation tool + support of a transition coach

Non-randomized controlled trial

Older people facing hospital discharge

Intv n = 158 (mean = 75)

Contr n = 1235 (mean = 78)

Primary: Complicated care episodes (=transitions to more intense level of care) within 30 days post-discharge

Secondary: Eight measures for re-hospitalization / ED admission

• No difference between the intervention group and control for complicated care episodes (9.5% vs 14.9%; OR = 0.74; 95% CI 0.38–1.46).

• Fewer re-hospitalizations within 30, 60 and 90 days in the intervention group as compared to control (8.9% vs 13.8%; OR = 0.52; 95% CI 0.28–0.96; 13.5% vs 22.9%; OR = 0.43; 95% CI 0.25–0.72; and 22.9% vs 32.0%; OR = 0.57; 95% CI 0.36–0.92 respectively).

• Fewer ED re-admissions within 90 days in the intervention group as compared to control (18.3% vs 25.7%; OR = 0.61; 95% CI 0.39–0.95).

• No difference in ED-readmissions between the intervention group and control at 30 and 180 days (11.0% vs 14.2%; OR = 0.76; 95% CI 0.44–1.30; and 37.1% vs 36.0%; OR = 1.16; 95% CI 0.78–1.72 respectively).

Grimmer, 2006, Australia [22]

Hospital discharge preparation tool

Before-after study

Older people facing hospital discharge

Intv n = 107 (mean = 70)

Contr n = 210 (mean = 69)

Primary: Quality of preparation for discharged (self-assessed).

Secondary: Experiences with managing at home, if hospital could have done more, and use of the tool.

• No significant differences in quality of discharge preparation (OR = 1.6 CI 95% 0.8–3.2) between pre- and post-cohorts; subjects in both cohorts were generally unaware of discharge plans made by hospital staff.

• In the intervention group, 89% found the tool relevant. It empowered them to plan ahead and deal with practical issues of returning home.

Polt, 2019, Austria [23]

Advance care planning for preferred place of death

Retrospective comparative study

Older people with palliative care at (nursing) home

Intv n = 38 (mean = 80)

Contr 1 n = 65 (mean = 74)

Contr 2 n = 755 (mean = 74)

Primary: Place of death

Secondary: Correspondence between preferred place of death and actual place of death

• Subjects in the intervention group more often died at home as compared to the control groups (72% vs. 53 and 57% for the two control groups; CIs or other statistical evaluations not given)

• Preferred place of death strongly correlated with actual place of death (p = 0.02 - correlation not reported).

Preen 2005, Australia [24]

Shared decision-making on a transition plan

Randomized controlled trial

Older people facing hospital discharge

Intv n = 91 (mean = 75)

Contr n = 98 (mean = 75)

Primary: Quality of life at 7 days post-discharge

Secondary: Fourteen aspects of satisfaction with transition at 7 days post-discharge

• No differences in physical quality of life between pre and post discharge in both intervention and control groups (− 2.2%, P = 0.45, − 3.9%, p = 0.28 respectively).

• Significant improvement in mental quality of life in the intervention group (13.4%, p < 0.01).

• No differences in mental quality of life between pre and post discharge in the control group 2.8%, p = 0.32) Improved of life aspects in intervention group.

• Intervention subjects were more positive on their input in the discharge process (difference of 11.1%, p = 0.09) and achievability of care-arrangements (difference of 10.1%, p < 0.01), they more often thought discharge was better than earlier discharges (difference of 22.8%, p < 0.01).

Schusselé Filliettaz, 2021, Switzerland [25]

Shared decision-making on a transition plan

Observational, descriptive study

Older people with and without complex needs

n = 453 (mean = 82)

Fidelity: Occurrence of 1) multilateral coordination processes, and 2) inter-professional and inter-institutional coordination meetings

Coverage: Comparison of the processes and meeting for people with and without complex needs; involvement in the processes and meetings.

• Fidelity: multilateral coordination processes occurred in 65% and inter-professional and inter-institutional coordination meetings occurred in 15% of the cases.

• Coverage: multilateral coordination processes occurred in 78% of people with complex needs vs 44% of people without complex needs (Chi2 = 57.09, p < 0.01); inter-professional and inter-institutional coordination meetings occurred in 24% of people with complex needs vs 1% of people without complex needs (Chi2 = 32.89; p < 0.01).

• Older people and informal caregivers were involved in 82% of the inter-professional and inter-institutional coordination meetings and 24% of the inter-professional and inter-institutional coordination meetings.

Toles, 2017, USA [26]

Shared decision-making on a transition plan

A non-randomized, historically controlled design

Older people facing discharge form skilled nursing facility to home and their informal caregivers

Intv n = 71 dyads

Older people (mean 80)

Informal caregivers (mean 64)

Contr n = 74 dyads

Older people (mean 80)

Informal caregivers (mean 64)

Primary: Older persons’ and informal caregivers’ preparedness for discharge, assessed with Care-Transitions Measure-15. (CTM-15).

Secondary: Feasibility based on chart reviews and relevance assessed with a survey for staff experiences.

• Intervention dyads, were more prepared for discharge as compared to dyads receiving usual care (CTM-15 score 74.7 vs 65.3, mean ratio 1.16, CI 95%: 1.08–1.24).

• The intervention was feasible and relevant to skilled nursing facilities staff (i.e., 96.9% of staff recommended intervention use in the future).

Tsui, 2015, Canada [27]

Hospital discharge preparation tool

Observational, descriptive study

Community-dwelling older people, after hospitalization for hip fracture n = 31 (mean = 78)

Informal carer n = 1 (NR)

Primary: Perceived utility of the discharge preparation tool.

Secondary: Open-ended questions on the tool’s structure, organization, content, and illustrations used.

• High scores for utility (median of 9 on 10-point scale).

• Medians > 4 on 5-point scale for all aspects of the tool.

• Favorable comments on tool overall; some suggestions for additional content and how hospital staff could go over the items with them.

Ulin, 2016, Sweden [28]

Shared decision-making on a transition plan

Non-randomized controlled trial

Older people with worsening chronic heart failure facing hospital discharge

Intv n = 125 (mean = 77)

Contr n = 123 (mean = 80)

Primary: Days from hospital admission to 1st notice to community care services.

Secondary: Days from admission to a) discharge planning conference; b) notification of discharge readiness.

• Fewer days from hospital admission to 1st notice to community care services in the intervention group, compared to control (2 days vs 14 days, p = NS).

• Fewer days from admission to discharge planning conference in the intervention group, compared with the usual care (23 days vs 28 days, p = 0.03).

• Fewer days from admission to notification of discharge readiness in the intervention group, compared with control (30 days vs 35 days, p = 0.01).