Abstract

Objective

To identify interventions in the literature that assist in promoting functionality in older adults during the hospital-to-home transition.

Method

Integrative literature review with searches conducted between October and November 2022, in the following databases: MEDLINE, Lilacs, IBECS, BDENF, WoS, SCOPUS, CINAHL, and PEDro, using the MeSH terms: Aged, Transitional Care, and Functional Status, in any language, without temporal restriction, employing boolean operators OR and AND.

Result

A total of 2,123 papers were identified, with nine meeting the inclusion criteria, resulting in four categories: Health education; Active involvement of older adults and family caregivers; Multidisciplinary team involvement; Follow-up care post-hospital discharge.

Conclusion

The continuity of care post-hospital discharge through interventions aimed at maintaining and restoring functionality is a strategy that strengthens the autonomy and independence of older adults.

Keywords
Transitional Care; Older Adult; Health Education; Functional Status

Resumo

Objetivo

Identificar na literatura, intervenções que auxiliam na promoção da funcionalidade da pessoa idosa durante a transição hospital domicílio.

Método

Revisão integrativa de literatura com buscas entre outubro e novembro de 2022, nas bases de dados: MEDLINE, Lilacs, IBECS, BDENF, WoS, SCOPUS, CINAHL e PEDro, com os MeSh: Aged, Transitional Care e Functional Status, em qualquer idioma, sem recorte temporal, com operador booleano OR e AND. Resultado: Identificou-se 2.123 artigos, nove atenderam aos critérios de inclusão, emergindo quatro categorias: Educação em saúde; Envolvimento ativo das pessoas idosas e cuidadores familiares; Atuação de equipe multidisciplinar; Acompanhamento após alta hospitalar.

Conclusão

A continuidade dos cuidados após alta hospitalar através de intervenções para manter e recuperar a funcionalidade é uma estratégia que fortalece a autonomia e a independência das pessoas idosas.

Palavras-Chave:
Cuidado Transicional; Idoso; Educação em saúde; Estado funcional

INTRODUCTION

The older adult during and after hospitalization, especially for long periods and due to various reasons, may experience impairments in physical function, including decreased strength and muscle mass, reduced aerobic capacity, and other deficits, which hinder the performance of Activities of Daily Living (ADLs), resulting in loss of functional independence and autonomy¹1 Barbosa BR, Almeida JM de, Barbosa MR, Rossi-Barbosa LAR. Avaliação da capacidade funcional dos idosos e fatores associados à incapacidade. Ciênc Saúde Coletiva. 2014;19:3317–25. Disponível em: https://doi.org/10.1590/1413-81232014198.06322013
https://doi.org/10.1590/1413-81232014198... . These impairments commonly persist after discharge, representing a poor prognosis for functional recovery²2 Dharmarajan K, Han L, Gahbauer EA, Leo-Summers LS, Gill TM. Disability and Recovery After Hospitalization for Medical Illness Among Community-Living Older Persons: A Prospective Cohort Study. J Am Geriatr Soc. 2020;68(3):486–95. Disponível em: 10.1111/jgs.16350.

Functionality, according to the International Classification of Functioning, Disability, and Health (ICF), refers to bodily functions, activities, and social participation³3 Organização Mundial da Saúde OP de S. Classificação Internacional de Funcionalidade, Incapacidade e Saúde [Internet]. 1o ed. São Paulo: Editora da Universidade de São Paulo; 2008 [acesso 16 set 2023]. Disponível em: <https://apps.who.int/iris/bitstream/handle/10665/42407/9788531407840_por.pdf?sequence=111>, considered by the World Health Organization (WHO) as a third health indicator for rehabilitation⁴4 Stucki G, Bickenbach J. Functioning: the third health indicator in the health system and the key indicator for rehabilitation. Eur J Phys Rehabil Med. 2017;53(1):134–8. Disponível em: 10.23736/S1973-9087.17.04565-8.

Furthermore, continuing to monitor older adults during hospitalization and after discharge is important for better adaptation at home⁵5 Costa MFBNA da, Sichieri K, Poveda V de B, Baptista CMC, Aguado PC. Transitional care from hospital to home for older people: implementation of best practices. Rev Bras Enferm. 2020;73:e20200187. Disponível em https://doi.org/10.1590/0034-7167-2020-0187
https://doi.org/10.1590/0034-7167-2020-0... . Recognizing this scenario, the WHO released in 2016 a framework for integrated and person-centered health services, emphasizing the need to optimize health systems and their linkages, particularly during care transitions⁶6 World Health Organization. Framework on integrated, people-centred health services [Internet]. 2016 [acesso 12 set 2021]. Disponível em: https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_39-en.pdf
https://apps.who.int/gb/ebwha/pdf_files/... .

In this context, the theory of transitions developed by Dr. Afaf Ibrahim Meleis supports individuals in transitional situations to experience the changes that the new health condition brings, anticipating and identifying strategies for better coping or not with situations that influence adaptation after discharge at home⁷7 Meleis AI, Sawyer LM, Im EO, Hilfinger Messias DK, Schumacher K. Experiencing transitions: an emerging middle-range theory. ANS Adv Nurs Sci. 2000;23(1):12-28. Disponível em: 10.1097/00012272-200009000-00006.

Although the promotion of functionality is widely addressed in the literature related to geriatrics and gerontology, there is still a gap, especially in Brazil, in studies that address the functionality of older adults as the main objective during the hospital-to-home transition, and regarding a consensus on how functionality should be assessed and addressed in this context.

Studies on this topic can guide healthcare services and their teams for better management/planning of hospital discharge, with interventions that promote functionality, and also contribute to scientific productions and better assistance in the field of geriatrics and gerontology. Thus, the objective of this study was to identify interventions in the literature that assist in promoting functionality in older adults during the hospital-to-home transition.

METHOD

Integrative literature review, conducted following five phases⁸8 Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546–53. Disponível em: 10.1111/j.1365-2648.2005.03621.x. The protocol was registered in the Open Science Framework (OSF) repository under the number 10.17605/OSF.IO/6DP9A.

The guiding question was formulated based on the PICo strategy, which represents P: older adult; I: interventions that assist in promoting functionality; Co: hospital-to-home transition, as follows: What interventions assist in promoting functionality in older adults during the hospital-to-home transition?

The following databases were utilized: Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Library, Latin American and Caribbean Literature on Health Sciences (Lilacs), Spanish Bibliographic Index in Health Sciences (IBECS), Brazilian Nursing Database (BDENF), Web of Science (WoS), SciVerseScopus (SCOPUS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Physiotherapy Evidence Database (PEDro). MEDLINE was accessed via PubMed. For LILACS, IBECS, and BDENF, the Virtual Health Library (VHL) website was used. For Cochrane Library, Web of Science, SCOPUS, and CINAHL, access was through the Portal of Periodicals of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) via login in the Federated Academic Community (CAFe) of the Universidade Federal da Bahia. The search on PEDro was conducted through the database's own website.

The searches took place between October 29 and November 26, 2022. Controlled vocabulary from the Medical Subject Headings (MeSH), as well as uncontrolled vocabulary (entry terms, synonyms, and keywords), were used. The MeSH terms Aged, Transitional Care, and Functional Status were combined with boolean operators "OR" and "AND", as presented in Chart 1.

The inclusion criteria were as follows: original papers published in any language, at any time, that addressed the research question, indicating as an outcome change in functionality during the hospital-to-home transition. Duplicate papers were excluded.

The search strategy identified 2,123 papers. Subsequently, Rayyan, a web application that assists in screening through a semi-automated process, was utilized⁹9 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 5 de dezembro de 2016;5(1):210. Disponível em: https://doi.org/10.1186/s13643-016-0384-4
https://doi.org/10.1186/s13643-016-0384-... . After duplicate papers were detected, 179 papers were excluded, leaving 1,944 for title and abstract screening. This stage was conducted by two independent researchers, in a blinded manner, resulting in the exclusion of 1,922 papers that did not address the theme. Eligibility criteria were applied, and justifications for exclusion were recorded in Rayyan. Seven discrepancies arose, which were resolved through discussion, leading to the inclusion of the respective papers.

The 22 eligible papers were read in their entirety, with nine papers that addressed the research question comprising the final sample (Figure 1). This search adhered to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)¹⁰10 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 29 de março de 2021;372:n71. Disponível em: 10.1136/bmj.n71.

Figure 1
Flowchart of the intersections and search results, based on PRISMA. Salvador, BA, 2023.

The data extracted from the papers were organized into a database in Microsoft Word.

The Level of Evidence of the studies was classified into six levels, according to the metrics proposed by Melnyk and Fineout-Overholt¹¹11 Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. 3o ed. Philadelphia: Wolters Kluwer Health; 2015. (2015): level I: meta-analyses and randomized controlled trials; level II: experimental studies; level III: quasi-experimental researches; level IV: descriptive studies, non-experimental, or qualitative; level V: case reports or experience; level VI: expert consensus and opinions.

Content Analysis was employed, guided by the phases: pre-analysis, material exploration, and result treatment for the formation of categories¹²12 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2016.. The results were analyzed in light of Meleis' Theory of Transitions, grounded in the changes prompted by the health-illness process and the necessary adaptations to experience the transitions⁷7 Meleis AI, Sawyer LM, Im EO, Hilfinger Messias DK, Schumacher K. Experiencing transitions: an emerging middle-range theory. ANS Adv Nurs Sci. 2000;23(1):12-28. Disponível em: 10.1097/00012272-200009000-00006.

DATA AVAILABILITY

The entire dataset supporting the findings of this study is available upon request to the corresponding author [Renata Farias Amorim].

RESULTS

Nine studies are included in this review. The general characteristics of these studies can be found in Chart 2. Four studies were conducted in Asia, three in North America, one in Oceania, and one in Eurasia, with publication periods ranging from 2004 to 2022, with 2019 having the highest number of publications (three).

Regarding the profile of participants in the studies, four addressed patients with heart disease¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x
https://doi.org/10.1111/j.1532-5415.2004... ,¹⁵15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02,¹⁹19 Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021;385(3):203–16. Disponível em: 10.1056/NEJMoa2026141,²⁰20 Coskun S, Duygulu S. The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46–55. Disponível em: 10.1093/eurjcn/zvab005, two focused on orthopedic patients¹⁸18 Ko Y, Lee J, Oh E, Choi M, Kim C, Sung K, et al. Older Adults With Hip Arthroplasty: An Individualized Transitional Care Program. Rehabil Nurs Off J Assoc Rehabil Nurses. 2019;44(4):203–12. Disponível em: 10.1097/rnj.0000000000000120,²¹21 Yang W, Xu H, Miao W, Geng Z, Geng G. Effects of transitional care based on the social support theory for older patients with osteoporotic vertebral compression fractures: A quasi-experimental trial. Australas J Ageing. 2023;42(1):185–94. Disponível em: 10.1111/ajag.13129, one on neurological patients¹⁷17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650, and two did not specify reasons for admission¹⁴14 Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Bradbury C, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34. Disponível em: 10.1111/j.1365-2753.2010.01547.x,¹⁶16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143. As for the design, one study used mixed methods, while eight employed quantitative methods. Five studies attained Level I evidence, one had Level II evidence, and three had Level III evidence.

Based on the collected material, four categories were formed for analysis and discussion: health education, active involvement of older individuals and family caregivers, multidisciplinary team involvement, and post-discharge follow-up (Chart 3).

DISCUSSION

In this review, a lack of primary studies in Brazil on the subject was observed, despite the emphasis given to functional status by the National Policy on Older Adult Health (PNSPI - Política Nacional de Saúde da Pessoa Idosa), where functionality is guided by the promotion of health actions and healthy aging²²22 Brasil. Portaria N. 2.528 de 19 de outubro de 2006. Aprova a Política Nacional de Saúde da Pessoa Idosa [Internet]. Portaria N.2528/2006, 2006. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html
https://bvsms.saude.gov.br/bvs/saudelegi... . This gap raises concerns, especially considering the constant increase in hospitalizations in this age group in the country, accounting for approximately one-third of all admissions in 2022²³23 Brasil. Ministério da Saúde. Departamento de informática do SUS - DATASUS [internet]. Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS); 2023 [acesso 15 jan 2023]. Disponível em: <http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/niuf.def>
http://tabnet.datasus.gov.br/cgi/tabcgi.... .

The disconnection of services provided by the Brazilian healthcare system, especially between primary care and tertiary care²⁴24 Mauro AD, Cucolo DF, Perroca MG. Hospital – primary care articulation in care transition: both sides of the process. Rev Esc Enferm USP. 2021;55:e20210145. Disponível em: https://doi.org/10.1590/1980-220X-REEUSP-2021-0145
https://doi.org/10.1590/1980-220X-REEUSP... , may present a barrier to the implementation of transitional care. Conversely, at the global level, there are mixed models, such as in the United States, which include subacute and post-acute care facilities, and specialized nursing facilities; in Australia and Canada, with the implementation of Transitional Care Programs²⁵25 McGilton KS, Vellani S, Krassikova A, Robertson S, Irwin C, Cumal A, et al. Understanding transitional care programs for older adults who experience delayed discharge: a scoping review. BMC Geriatr. 2021;21(1):210. Disponível em: 10.1186/s12877-021-02099-9.

Patient follow-up in this review ranged from two weeks to six months, with a predominance of three months in 44% of the studies¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x
https://doi.org/10.1111/j.1532-5415.2004... ,¹⁵15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02

16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143-¹⁷17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650. However, the absence of a consensus regarding the ideal duration of intervention during care transition was highlighted, indicating the need for further research to formulate protocols, as the hospitalization process leads to functional decline due to the association of factors such as physiological changes of aging, illness, and hospital routines²⁶26 Tavares JP de A, Nunes LANV, Grácio JCG. Hospitalized older adult: predictors of functional decline. Rev Lat Am Enfermagem. 2021;29:e3399. Disponível em: https://doi.org/10.1590/1518-8345.3612.3399
https://doi.org/10.1590/1518-8345.3612.3... . These factors result in mobility disorders, increased risk of falls, and impaired autonomy in performing activities of daily living²⁷27 Wang MC, Liao WC, Lee KC, Lu SH, Lin YP. Validation of Screening Tools for Predicting the Risk of Functional Decline in Hospitalized Elderly Patients. Int J Environ Res Public Health. 2022;19(11):6685. Disponível em: 10.3390/ijerph19116685,²⁸28 Falvey JR, Burke RE, Malone D, Ridgeway KJ, McManus BM, Stevens-Lapsley JE. Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community. Phys Ther. 2016;96(8):1125–34. Disponível em: https://doi.org/10.2522/ptj.20150526
https://doi.org/10.2522/ptj.20150526... .

In this review, studies indicated clinically-originated hospitalizations¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x
https://doi.org/10.1111/j.1532-5415.2004...

14 Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Bradbury C, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34. Disponível em: 10.1111/j.1365-2753.2010.01547.x

15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02

16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143-¹⁷17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650,¹⁹19 Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021;385(3):203–16. Disponível em: 10.1056/NEJMoa2026141, involving individuals with cardiac problems. In this context, heart failure is the primary cause of hospitalizations in older individuals, being associated with impairments in physical function, leading to multiple admissions²⁹29 Kitzman DW, Haykowsky MJ, Tomczak CR. Making the Case for Skeletal Muscle Myopathy and Its Contribution to Exercise Intolerance in Heart Failure With Preserved Ejection Fraction. Circ Heart Fail. 2017;10(7):e004281. Disponível em: 10.1161/CIRCHEARTFAILURE.117.0042814. One study implemented a transition program, yielding no significant results in physical function¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x
https://doi.org/10.1111/j.1532-5415.2004... , while two others focused on physical exercises such as walking, demonstrating functional improvements¹⁵15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02,¹⁹19 Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021;385(3):203–16. Disponível em: 10.1056/NEJMoa2026141. Although a set of self-care actions positively impacts functionality and other health outcomes, personalized and progressive physical exercise enhances physical function in cardiac patients within the transition context²⁹29 Kitzman DW, Haykowsky MJ, Tomczak CR. Making the Case for Skeletal Muscle Myopathy and Its Contribution to Exercise Intolerance in Heart Failure With Preserved Ejection Fraction. Circ Heart Fail. 2017;10(7):e004281. Disponível em: 10.1161/CIRCHEARTFAILURE.117.0042814.

Among the interventions used in the studies to promote functionality, highlighted were health information-based trainings and active participation of older adults and caregivers along with a multidisciplinary team in decision-making for self-health management³⁰30 Nakahara-Melo M, Conceição AP da, Cruz D de ALM da, Püschel VA de A. Transitional care from the hospital to the home in heart failure: implementation of best practices. Rev Bras Enferm. 2022;75(1):e20210123. Disponível em: https://doi.org/10.1590/0034-7167-2021-0123
https://doi.org/10.1590/0034-7167-2021-0...

31 Butler J, Petrie MC, Bains M, Bawtinheimer T, Code J, Levitch T, et al. Challenges and opportunities for increasing patient involvement in heart failure self-care programs and self-care in the post–hospital discharge period. Res Involv Engagem. 2023;9(1):23. Disponível em: 10.1186/s40900-023-00412-x-³²32 Liu S, Xiong X yun, Chen H, Liu M die, Wang Y, Yang Y, et al. Transitional Care in Patients with Heart Failure: A Concept Analysis Using Rogers’ Evolutionary Approach. Risk Manag Healthc Policy. 2023;16:2063–76. Disponível em: 10.2147/RMHP.S427495. Health education was utilized in 89% of the studies¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x
https://doi.org/10.1111/j.1532-5415.2004...

14 Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Bradbury C, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34. Disponível em: 10.1111/j.1365-2753.2010.01547.x

15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02

16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143

17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650-¹⁸18 Ko Y, Lee J, Oh E, Choi M, Kim C, Sung K, et al. Older Adults With Hip Arthroplasty: An Individualized Transitional Care Program. Rehabil Nurs Off J Assoc Rehabil Nurses. 2019;44(4):203–12. Disponível em: 10.1097/rnj.0000000000000120,²⁰20 Coskun S, Duygulu S. The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46–55. Disponível em: 10.1093/eurjcn/zvab005,²¹21 Yang W, Xu H, Miao W, Geng Z, Geng G. Effects of transitional care based on the social support theory for older patients with osteoporotic vertebral compression fractures: A quasi-experimental trial. Australas J Ageing. 2023;42(1):185–94. Disponível em: 10.1111/ajag.13129, aiming at empowering the population with knowledge on health-related topics, thus increasing people's autonomy in their own care³³33 Brasil. Ministério da Saúde. Secretaria-Executiva. Secretaria de Gestão do Trabalho e da Educação na Saúde. Glossário temático: gestão do trabalho e da educação na saúde. 2o ed. Brasília: Ministério da Saúde; 2013..

Adaptations are promoted through knowledge, development of strategies, and skills via individual psychosocial resources and competencies. However, to achieve this, it is necessary to actively involve participants in the care process, as well as in decision-making. By engaging individuals in their self-care, it is possible to promote awareness and, consequently, engagement, important elements for a healthy transition as outlined by Meleis⁷7 Meleis AI, Sawyer LM, Im EO, Hilfinger Messias DK, Schumacher K. Experiencing transitions: an emerging middle-range theory. ANS Adv Nurs Sci. 2000;23(1):12-28. Disponível em: 10.1097/00012272-200009000-00006.

Active participant involvement was observed in 66% of the studies¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x
https://doi.org/10.1111/j.1532-5415.2004... ,¹⁵15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02

16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143

17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650-¹⁸18 Ko Y, Lee J, Oh E, Choi M, Kim C, Sung K, et al. Older Adults With Hip Arthroplasty: An Individualized Transitional Care Program. Rehabil Nurs Off J Assoc Rehabil Nurses. 2019;44(4):203–12. Disponível em: 10.1097/rnj.0000000000000120,²⁰20 Coskun S, Duygulu S. The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46–55. Disponível em: 10.1093/eurjcn/zvab005. This occurs when the care plan is aligned with the preferences, values, and goals of older adults and their family caregivers³⁴34 Lawton R, Murray J, Baxter R, Richardson G, Cockayne S, Baird K, et al. Evaluating an intervention to improve the safety and experience of transitions from hospital to home for older people (Your Care Needs You): a protocol for a cluster randomised controlled trial and process evaluation. Trials. 2023;24(1):671. Disponível em: 10.1186/s13063-023-07716-z-³⁵35 Morkisch N, Upegui-Arango LD, Cardona MI, van den Heuvel D, Rimmele M, Sieber CC, et al. Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a systematic review. BMC Geriatr. 2020;20(1):345. Disponível em: 10.1186/s12877-020-01747-w. Authors have shown that transition care models directly involving individuals in their care have reduced hospital readmissions and caregiver stress³⁰30 Nakahara-Melo M, Conceição AP da, Cruz D de ALM da, Püschel VA de A. Transitional care from the hospital to the home in heart failure: implementation of best practices. Rev Bras Enferm. 2022;75(1):e20210123. Disponível em: https://doi.org/10.1590/0034-7167-2021-0123
https://doi.org/10.1590/0034-7167-2021-0... ,³⁶36 Maleki M, Mardani A, Iloonkashkooli R, Khachian A, Glarcher M, Vaismoradi M. The effect of hospital-to-home transitional care using a digital messaging application on the health outcomes of patients undergoing CABG and their family caregivers: a randomized controlled trial study protocol. Front Cardiovasc Med. 2023;10:1224302. Disponível em: 10.3389/fcvm.2023.1224302,³⁷37 Sun M, Liu L, Wang J, Zhuansun M, Xu T, Qian Y, et al. Facilitators and inhibitors in hospital-to-home transitional care for elderly patients with chronic diseases: A meta-synthesis of qualitative studies. Front Public Health. 2023;11:1047723. Disponível em: 10.3389/fcvm.2023.1224302. Furthermore, during the process, the multidisciplinary team should pay attention to caregivers, as their burden and accumulation of responsibilities add to the challenges of establishing a good relationship with the team and, consequently, a successful transition³⁷37 Sun M, Liu L, Wang J, Zhuansun M, Xu T, Qian Y, et al. Facilitators and inhibitors in hospital-to-home transitional care for elderly patients with chronic diseases: A meta-synthesis of qualitative studies. Front Public Health. 2023;11:1047723. Disponível em: 10.3389/fcvm.2023.1224302,³⁸38 Kraun L, De Vliegher K, Vandamme M, Holtzheimer E, Ellen M, van Achterberg T. Older peoples’ and informal caregivers’ experiences, views, and needs in transitional care decision-making: a systematic review. Int J Nurs Stud. 2022;134:104303. Disponível em: 10.1016/j.ijnurstu.2022.104303.

According to Meleis⁷7 Meleis AI, Sawyer LM, Im EO, Hilfinger Messias DK, Schumacher K. Experiencing transitions: an emerging middle-range theory. ANS Adv Nurs Sci. 2000;23(1):12-28. Disponível em: 10.1097/00012272-200009000-00006, transformations resulting from the new health condition generate conceptions, thoughts, coping mechanisms, roles, and response patterns to the new situation, known as adaptations. Thus, individuals in care transition feel the need to be supported by a professional to clarify their doubts³⁹39 Pedrosa ARC, Ferreira ÓR, Baixinho CRSL. Transitional rehabilitation care and patient care continuity as an advanced nursing practice. Rev Bras Enferm. 2022;75:e20210399. Disponível em: https://doi.org/10.1590/0034-7167-2021-0399
https://doi.org/10.1590/0034-7167-2021-0... .

The majority of studies in this review utilized a multidisciplinary team approach¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x
https://doi.org/10.1111/j.1532-5415.2004... ,¹⁵15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02

16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143-¹⁷17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650,²⁰20 Coskun S, Duygulu S. The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46–55. Disponível em: 10.1093/eurjcn/zvab005. The implementation of multidisciplinarity in healthcare involves sharing knowledge, enhancing actions, and commitment to users³³33 Brasil. Ministério da Saúde. Secretaria-Executiva. Secretaria de Gestão do Trabalho e da Educação na Saúde. Glossário temático: gestão do trabalho e da educação na saúde. 2o ed. Brasília: Ministério da Saúde; 2013.. However, the nurse was the most cited healthcare professional¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x
https://doi.org/10.1111/j.1532-5415.2004...

14 Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Bradbury C, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34. Disponível em: 10.1111/j.1365-2753.2010.01547.x

15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02

16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143

17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650-¹⁸18 Ko Y, Lee J, Oh E, Choi M, Kim C, Sung K, et al. Older Adults With Hip Arthroplasty: An Individualized Transitional Care Program. Rehabil Nurs Off J Assoc Rehabil Nurses. 2019;44(4):203–12. Disponível em: 10.1097/rnj.0000000000000120,²⁰20 Coskun S, Duygulu S. The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46–55. Disponível em: 10.1093/eurjcn/zvab005,²¹21 Yang W, Xu H, Miao W, Geng Z, Geng G. Effects of transitional care based on the social support theory for older patients with osteoporotic vertebral compression fractures: A quasi-experimental trial. Australas J Ageing. 2023;42(1):185–94. Disponível em: 10.1111/ajag.13129. Their role as coordinator of care transition is highlighted in a large part of the national and international scientific literature³⁵35 Morkisch N, Upegui-Arango LD, Cardona MI, van den Heuvel D, Rimmele M, Sieber CC, et al. Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a systematic review. BMC Geriatr. 2020;20(1):345. Disponível em: 10.1186/s12877-020-01747-w,³⁹39 Pedrosa ARC, Ferreira ÓR, Baixinho CRSL. Transitional rehabilitation care and patient care continuity as an advanced nursing practice. Rev Bras Enferm. 2022;75:e20210399. Disponível em: https://doi.org/10.1590/0034-7167-2021-0399
https://doi.org/10.1590/0034-7167-2021-0... ,⁴⁰40 Santos JMD, Pedreira LC, Góes RP, Amaral JBD, Baixinho CL, Souza MAAD. Influência das ações dos profissionais de saúde na adaptação de pessoas idosas em domicílio após internamento por quedas: revisão integrativa. Rev Bras Geriatr e Gerontol. 2023;26:e230162. Disponível em: https://doi.org/10.1590/1981-22562023026.230162.pt
https://doi.org/10.1590/1981-22562023026... , although authors point out the capacity of other professional categories to assume this coordination³⁵35 Morkisch N, Upegui-Arango LD, Cardona MI, van den Heuvel D, Rimmele M, Sieber CC, et al. Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a systematic review. BMC Geriatr. 2020;20(1):345. Disponível em: 10.1186/s12877-020-01747-w, such as physiotherapists and kinesiologists in a study where the intervention was based on physical training¹⁹19 Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021;385(3):203–16. Disponível em: 10.1056/NEJMoa2026141.

Post-discharge follow-up occurred in the majority of studies¹²12 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2016.

13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x
https://doi.org/10.1111/j.1532-5415.2004...

14 Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Bradbury C, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34. Disponível em: 10.1111/j.1365-2753.2010.01547.x

15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02

16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143-¹⁷17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650,¹⁹19 Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021;385(3):203–16. Disponível em: 10.1056/NEJMoa2026141

20 Coskun S, Duygulu S. The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46–55. Disponível em: 10.1093/eurjcn/zvab005-²¹21 Yang W, Xu H, Miao W, Geng Z, Geng G. Effects of transitional care based on the social support theory for older patients with osteoporotic vertebral compression fractures: A quasi-experimental trial. Australas J Ageing. 2023;42(1):185–94. Disponível em: 10.1111/ajag.13129. Authors claim that this prevents the interruption of care when transitioning between environments³⁴34 Lawton R, Murray J, Baxter R, Richardson G, Cockayne S, Baird K, et al. Evaluating an intervention to improve the safety and experience of transitions from hospital to home for older people (Your Care Needs You): a protocol for a cluster randomised controlled trial and process evaluation. Trials. 2023;24(1):671. Disponível em: 10.1186/s13063-023-07716-z,³⁹39 Pedrosa ARC, Ferreira ÓR, Baixinho CRSL. Transitional rehabilitation care and patient care continuity as an advanced nursing practice. Rev Bras Enferm. 2022;75:e20210399. Disponível em: https://doi.org/10.1590/0034-7167-2021-0399
https://doi.org/10.1590/0034-7167-2021-0... , and interventions initiated before discharge, continuing afterward, are more effective in reducing hospital readmissions⁴⁰40 Santos JMD, Pedreira LC, Góes RP, Amaral JBD, Baixinho CL, Souza MAAD. Influência das ações dos profissionais de saúde na adaptação de pessoas idosas em domicílio após internamento por quedas: revisão integrativa. Rev Bras Geriatr e Gerontol. 2023;26:e230162. Disponível em: https://doi.org/10.1590/1981-22562023026.230162.pt
https://doi.org/10.1590/1981-22562023026... . However, one study did not conduct follow-up after discharge¹⁸18 Ko Y, Lee J, Oh E, Choi M, Kim C, Sung K, et al. Older Adults With Hip Arthroplasty: An Individualized Transitional Care Program. Rehabil Nurs Off J Assoc Rehabil Nurses. 2019;44(4):203–12. Disponível em: 10.1097/rnj.0000000000000120, basing the intervention solely on planning and preparation for returning home. In this study, involving older adults undergoing hip arthroplasty, the intervention took place during hospitalization, with assessments following the theory of transitions⁷7 Meleis AI, Sawyer LM, Im EO, Hilfinger Messias DK, Schumacher K. Experiencing transitions: an emerging middle-range theory. ANS Adv Nurs Sci. 2000;23(1):12-28. Disponível em: 10.1097/00012272-200009000-00006 at pre- and post-surgery moments. The intervention group showed reduced functional decline, improved scores for Activities of Daily Living (ADLs) and walking speed, as well as decreased fear of falling.

During post-discharge follow-up, the studies included in this review utilized home assessments to suggest interventions for improving the environment, adapting it, and reducing architectural barriers. Thus, home visits were conducted in five studies¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x
https://doi.org/10.1111/j.1532-5415.2004... ,¹⁴14 Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Bradbury C, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34. Disponível em: 10.1111/j.1365-2753.2010.01547.x, ¹⁷17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650,¹⁹19 Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021;385(3):203–16. Disponível em: 10.1056/NEJMoa2026141,²⁰20 Coskun S, Duygulu S. The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46–55. Disponível em: 10.1093/eurjcn/zvab005. Home assessment, whether through photography or in-person visits, helps the multidisciplinary team identify barriers and facilitators for transition⁴⁰40 Santos JMD, Pedreira LC, Góes RP, Amaral JBD, Baixinho CL, Souza MAAD. Influência das ações dos profissionais de saúde na adaptação de pessoas idosas em domicílio após internamento por quedas: revisão integrativa. Rev Bras Geriatr e Gerontol. 2023;26:e230162. Disponível em: https://doi.org/10.1590/1981-22562023026.230162.pt
https://doi.org/10.1590/1981-22562023026... , aiding in the creation of strategies and coping mechanisms, preventing situations, and empowering potentialities for a new reorganization of the social and family context. According to Meleis⁷7 Meleis AI, Sawyer LM, Im EO, Hilfinger Messias DK, Schumacher K. Experiencing transitions: an emerging middle-range theory. ANS Adv Nurs Sci. 2000;23(1):12-28. Disponível em: 10.1097/00012272-200009000-00006, preparation of the environment and necessary economic aspects act as facilitators for transition.

As a follow-up strategy, telephone calls were utilized by the majority of studies¹³13 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc. 2004;52(5):675–84. Disponível em: https://doi.org/10.1111/j.1532-5415.2004.52202.x
https://doi.org/10.1111/j.1532-5415.2004...

14 Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Bradbury C, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34. Disponível em: 10.1111/j.1365-2753.2010.01547.x

15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02

16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143-¹⁷17 Geng G, He W, Ding L, Klug D, Xiao Y. Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model. Top Stroke Rehabil. dezembro de 2019;26(8):621–9. Disponível em: 10.1080/10749357.2019.1647650,¹⁹19 Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021;385(3):203–16. Disponível em: 10.1056/NEJMoa2026141

20 Coskun S, Duygulu S. The effects of Nurse Led Transitional Care Model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46–55. Disponível em: 10.1093/eurjcn/zvab005-²¹21 Yang W, Xu H, Miao W, Geng Z, Geng G. Effects of transitional care based on the social support theory for older patients with osteoporotic vertebral compression fractures: A quasi-experimental trial. Australas J Ageing. 2023;42(1):185–94. Disponível em: 10.1111/ajag.13129. Phone calls assist in effective transition, addressing gaps in care and residual doubts, and have proven effective in other studies⁴¹41 Bhandari N, Epane J, Reeves J, Cochran C, Shen J. Post-Discharge Transitional Care Program and Patient Compliance With Follow-Up Activities. J Patient Exp. 2022;9:23743735221086756. Disponível em: 10.1177/23743735221086756,⁴²42 Jones B, James P, Vijayasiri G, Li Y, Bozaan D, Okammor N, et al. Patient Perspectives on Care Transitions From Hospital to Home. JAMA Netw Open. 2022;5(5):e2210774. Disponível em: 10.1001/jamanetworkopen.2022.10774. However, authors suggest between two to three calls after returning home, as a single call was insufficient to promote adherence to the discharge plan⁴¹41 Bhandari N, Epane J, Reeves J, Cochran C, Shen J. Post-Discharge Transitional Care Program and Patient Compliance With Follow-Up Activities. J Patient Exp. 2022;9:23743735221086756. Disponível em: 10.1177/23743735221086756.

Regarding physical rehabilitation protocols, interventions with exercises and/or walking¹⁴14 Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Bradbury C, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34. Disponível em: 10.1111/j.1365-2753.2010.01547.x,¹⁵15 Xueyu L, Hao Y, Shunlin X, Rongbin L, Yuan G. Effects of Low-Intensity Exercise in Older Adults With Chronic Heart Failure During the Transitional Period From Hospital to Home in China: A Randomized Controlled Trial. Res Gerontol Nurs. 2017;10(3):121–8. Disponível em: 10.3928/19404921-20170411-02,¹⁶16 Carvalho LP, Kergoat MJ, Bolduc A, Aubertin-Leheudre M. A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study. J Am Med Dir Assoc. outubro de 2019;20(10):1287–93. Disponível em: 10.1016/j.jamda.2019.01.143,¹⁹19 Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021;385(3):203–16. Disponível em: 10.1056/NEJMoa2026141 as the main component achieved positive results in functionality, although a systematic review observed few consistent changes in physical health or independent functioning of participants⁴³43 O’Donnell R, Savaglio M, Skouteris H, Banaszak-Holl J, Moranl C, Morris H, et al. The Effectiveness of Transition Interventions to Support Older Patients From Hospital to Home: A Systematic Scoping Review. J Appl Gerontol Off J South Gerontol Soc. 2021;40(11):1628–36. Disponível em: 10.1177/0733464820968712.

The scientific literature²2 Dharmarajan K, Han L, Gahbauer EA, Leo-Summers LS, Gill TM. Disability and Recovery After Hospitalization for Medical Illness Among Community-Living Older Persons: A Prospective Cohort Study. J Am Geriatr Soc. 2020;68(3):486–95. Disponível em: 10.1111/jgs.16350,²⁵25 McGilton KS, Vellani S, Krassikova A, Robertson S, Irwin C, Cumal A, et al. Understanding transitional care programs for older adults who experience delayed discharge: a scoping review. BMC Geriatr. 2021;21(1):210. Disponível em: 10.1186/s12877-021-02099-9,²⁸28 Falvey JR, Burke RE, Malone D, Ridgeway KJ, McManus BM, Stevens-Lapsley JE. Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community. Phys Ther. 2016;96(8):1125–34. Disponível em: https://doi.org/10.2522/ptj.20150526
https://doi.org/10.2522/ptj.20150526... ,²⁹29 Kitzman DW, Haykowsky MJ, Tomczak CR. Making the Case for Skeletal Muscle Myopathy and Its Contribution to Exercise Intolerance in Heart Failure With Preserved Ejection Fraction. Circ Heart Fail. 2017;10(7):e004281. Disponível em: 10.1161/CIRCHEARTFAILURE.117.0042814,³⁷37 Sun M, Liu L, Wang J, Zhuansun M, Xu T, Qian Y, et al. Facilitators and inhibitors in hospital-to-home transitional care for elderly patients with chronic diseases: A meta-synthesis of qualitative studies. Front Public Health. 2023;11:1047723. Disponível em: 10.3389/fcvm.2023.1224302,³⁸38 Kraun L, De Vliegher K, Vandamme M, Holtzheimer E, Ellen M, van Achterberg T. Older peoples’ and informal caregivers’ experiences, views, and needs in transitional care decision-making: a systematic review. Int J Nurs Stud. 2022;134:104303. Disponível em: 10.1016/j.ijnurstu.2022.104303,⁴⁰40 Santos JMD, Pedreira LC, Góes RP, Amaral JBD, Baixinho CL, Souza MAAD. Influência das ações dos profissionais de saúde na adaptação de pessoas idosas em domicílio após internamento por quedas: revisão integrativa. Rev Bras Geriatr e Gerontol. 2023;26:e230162. Disponível em: https://doi.org/10.1590/1981-22562023026.230162.pt
https://doi.org/10.1590/1981-22562023026... alerts to the need to observe, prevent, and intervene in functional deficits for transitions between care settings. Older adults and caregivers require support from professionals, social networks, and healthcare to experience favorable outcomes with continued interventions in the home environment aimed at improving functional capacity when possible. Research needs to advance in transition models that include feasible physical interventions to guide healthcare professionals and support older adults and caregivers.

This review was limited by the lack of national scientific production during this period, which hindered the visualization of the Brazilian reality on the subject.

CONCLUSION

Among the interventions that assist in promoting the functionality of older adults during the hospital-to-home transition, actions based on monitoring and follow-up after hospital discharge, active involvement of older adults and family caregivers, and the multidisciplinary team, health education, and interventions based on exercise programs and walking stand out.

The study revealed that for promoting functionality in hospital-to-home transition care, it is necessary to build a discharge plan directed towards physical function to prevent and/or mitigate functional impairment, as actions for promoting physical function are often given low priority in clinical practice.

Therefore, the review highlights the need for further research, particularly in Brazil, addressing transition care interventions more definitively, aiming to maintain and restore the functionality of older adults after hospitalization.

REFERÊNCIAS

Edited by

Data availability

Publication Dates

History