Table 2 Summary description of the TCIs’ elements as mapped to the six core components of transitional care

1. Patient Engagement

▪ Establishment of trusting relationship with patient

▪ Development of rapport with patient, and understand the patient’s goals and preferences

▪ Active engagement of patient, family caregivers, and collaboration with primary care providers

▪ Active involvement of patients and informal caregivers for example in a triage decision-making for care transitions

▪ Integration of psychotherapeutic methods in care coordination and case management to increase patient engagement (e.g., motivational interviewing and behavioral activation)

2. Caregiver Engagement

▪ Establishment of trusting relationship with caregiver

▪ Active engagement of patient, family caregivers, and collaboration with primary care providers

▪ Active involvement of patients and informal caregivers for example in a triage decision for care transitions

3. Patient Education

▪ Discharge planning using “teach-back” methods

▪ Active engagement of patients and their family or informal caregivers by focusing on education and support

▪ Improvement of patient’s capacity in: medication self-management, using a patient-centered health record, knowledge of “red flags”, and making primary care provider/specialist appointments

▪ Provision of patient and caregiver education tools

▪ Coordination of education and community services to develop self-management skills

▪ Provision of a 30-day post-acute care bundle of transitional care services

4. Caregiver Education

▪ Building of the caregiver’s ability to identify early symptoms and apply strategies to prevent poor outcomes for patient

▪ Active engagement of patients and their family or informal caregivers by focusing on education and support

▪ Provision of patient and caregiver education tools

5. Complexity Management

▪ Development of individualized care plans, patient-caregiver goals (with patient, caregiver, and healthcare providers)

▪ Implementation of risk reduction strategies to minimize effects for example of cognitive impairment

▪ Daily hospital visits to patient-caregiver dyad as well as pre-discharge

▪ In-hospital patient case assessment and development of care plan

▪ Advanced care planning (assessment of needs at patient home and building a tailored care plan)

▪ Early identification and response to health risks of patient

▪ Comprehensive patient assessment within 3 days upon discharge by a home care nurse

▪ Development of a care plan based on input from patient and caregiver as well as a biopsychosocial needs assessment (post-discharge)

▪ Provision for example of a triage instrument for in-hospital assessment of patient needs for admission to a geriatric-rehabilitation unit before movement to a home setting

▪ Provision of acute-level care services at home as a substitute for hospital admission

▪ Identification, assessment, and management of acute conditions in a nursing home, such as evaluation, and communication of the resident status changes using communication tools (stop and watch warning tool), decision support (care pathways), and advance care planning

▪ Provision of a patient-centered holistic approach

6. Care Continuity^a

Majority of elements in this core component include a “Transition Role” with various tasks, described below

▪ Presence of staff with a transition role such as Advanced Practice Nurse to perform:

✓ home/nursing facility visits 24 h post-discharge

✓ telephone follow-up and support

✓ coordination with a multidisciplinary local team of healthcare experts

▪ Presence of staff with a transition role such as Transitional Care Manager (social worker, or any other healthcare professional) to perform:

✓ discharge planning by management of environmental and community barriers

✓ coordination of transitional care (e.g., implementing home care, organizing home visits by professionals, delivering equipment to patient home, contacting long-term care placement agency, and reorienting patient when needed to rehabilitation services)

✓ exchange of patient information between providers

▪ Presence of staff with a transition role such as Health Coach (nurse or social worker) to perform:

✓ home visits (within 24–48 h) post-discharge

✓ follow-up phone calls and appointments with primary care providers

✓ connecting older adults to community services and resources

▪ Presence of staff with a transition role such as Hospital Care Transition Nurse to perform:

✓ patient care handoff between hospital care transition nurse and community rapid response nurse

✓ home care and follow-up period up to 30 days

✓ referral to hospital-based chronic disease management clinics

▪ Presence of staff with a transition role such as Transitional Care Nurse to perform:

✓ care coordination among providers and ensuring a multidisciplinary approach with open communication

✓ regular home visits and ongoing telephone support (7 days/week over 2 months post-discharge)

✓ continuity of medical care with hospital/primary care and accompanying patients on follow-up visits

▪ Presence of staff with transition role such as Care Coordinator to perform:

✓ home visits, telephone monitoring

✓ care coordination with a network of medical and social care providers in/out of hospital (including: symptoms management, functional management, psycho-support, medication management, promotion of self-care, referral to other services, appointment management, management of social issues, assessment of home environment)

▪ Presence of staff with transition role such as Transition Coach (nurse or social worker), to perform home visits post-discharge and follow-up telephone calls

▪ Presence of staff with transition role such as Care Coordinator (social worker) to perform:

✓ care coordination and follow-up in person or by telephone throughout 30 days post-discharge (e.g. provide brief counseling, arrange services and follow-ups, collaborate with other healthcare and social service providers)

▪ Presence of staff with transition role such as Care Pathway Coordinator in order to perform:

✓ coordination and continuity of care across settings

▪ Exchange of patient discharge information between the hospital, local healthcare allocations (municipality-level), and home care services, in order to:

✓ evaluate and decide on care assistance

✓ prepare home care service for transition

✓ provide general practitioner consults to patient 14 days post-discharge

✓ perform extended assessment during the first 4 weeks by district nurse/nursing assistant

▪ Delivery of transition care in temporary transition care places (e.g., low-intensity therapies and services, case management, and finalization of long-term care arrangements)

▪ Provision of community geriatric services (e.g., geriatrician and community nurse, 24 h telephone support and advisory service to nursing facility staff)

▪ Collaboration of hospital and community-based organizations for aging services (network collaboration)

▪ Availability of a Community Psychiatric Nurse, to perform follow-up visits and provide support/advice to family caregivers and facility nurses after the placement of an older person in a nursing home facility

▪ Provision of a 30-day post-acute period of transitional care bundle care coordination

▪ Combination of disease management in primary care settings and home care by coordinating care during an episode of acute illness across settings, and facilitated by a transitional care nurse