Older adults who have been recently hospitalized are at high risk of functional decline and re-hospitalization.1 There is strong evidence that approximately 30% of older adults have reduced ability to perform one or more activities of daily living (ADL) after hospital discharge compared to pre-admission.2,3 Many older adults who require hospital admission are frail and have multiple comorbidities.2,3 Hospital-caused functional decline superimposed on existing comorbidities may prevent older adults from returning to independent living in the community, resulting in hospital readmissions, which in turn can lead to further functional decline, and may also subsequently lead to admission into residential aged care (RAC).1-5 Additionally, although older adults comprised 42% of all hospital admissions in Australia in 2016–17, 90% of these admissions were episodes of acute care and only 7% were episodes of rehabilitation care.6 These data indicate that most older patients do not receive rehabilitation care following an episode of acute care, but are discharged directly home, regardless of possible functional decline. A national Australian report (2008–09) found that approximately 4.4% (47,000) of older adults discharged from hospital had completed transition care programs (TCPs; 1.0%), were transferred to respite care in RAC (1.2%), or entered RAC permanently (2.2%).7,8 Hence, it is vital to assist older adults to regain their pre-morbid functional ability and overall health in order to prevent unnecessary hospital readmissions or premature RAC admission.9
Multiple national health care services have established rehabilitation programs, including TCPs, to provide rehabilitation for older adults after hospitalization.10-20 Transition care programs and similar programs, such as rehabilitation in the home, aim to enable older adults to regain the functional level required to successfully transition from hospital to independent community living.10-20 Transition care programs were established in Australia in 2004, while an equivalent service known as “intermediate care” was established in the United Kingdom (UK) in 2001 to provide older people with continuum of care after hospital discharge.10-13 Transition care programs aim to facilitate safe recovery after an acute episode of care in hospital, while maximizing older adults’ functional independence prior to returning home.10-13 Transition care programs are also known as skilled nursing facility care in the United States (US),10,14 intermediate care15,16 (delivered in a TCP facility) or restorative care16,17 (delivered at home in the community) in New Zealand, slow stream rehabilitation in Canada18 and geriatric intermediate care19,20 in Japan. Programs in these countries also aim to assist older adults to regain functional ability in order to return home.10,14-20 Skilled nursing facility care in the US provides rehabilitation programs that are similar to TCPs except that Medicare in the US only provides financial assistance for older adults undertaking TCPs for up to 100 days.10,14 Slow-stream rehabilitation in Canada consists of low intensity therapy of 20 minutes three times per week initially for a maximum duration of 120 days.18 Transition care programs in both the US and Canada are provided in either home or facility settings.14,18 The key difference between intermediate or restorative care in New Zealand and TCPs delivered in Australia is that in New Zealand designated caregivers are assigned to eligible older adults for up to 12 weeks.15-17 The New Zealand intermediate care programs are delivered in facilities rather than at home, and the rehabilitation specialist/geriatrician leads the development of a suitable rehabilitation program.15-17 Similarly to TCPs in Australia, geriatric intermediate care facilities in Japan also provide facility-based rehabilitation for older adults for up to three months to facilitate discharge home. Programs in Japan also promote rehabilitation that addresses challenging behaviors and physical comorbidities in older adults diagnosed with dementia.19,20
Older adults are eligible for six to12 weeks of rehabilitation through TCPs in Australia,13,21 and up to six weeks in the UK either in hospital, a transition care facility, or the older adult's home.10,11 Eligibility criteria include the patient requiring increased levels of independence to undertake personal or instrumental ADL, assistance with addressing psychological problems, or increased social support.13,22,23 Rehabilitation delivered via TCPs broadly comprise case management by an allied health team, either at the patient's home or in a facility.13,23 Therapy provided by the team usually consists of physiotherapy, occupational therapy, and/or speech pathology. Therapy is individually tailored for each patient and aims to improve physical, cognitive, and psychosocial function to enable a successful return to independent community living.13,23 Medical services, including medication reviews, are provided by a general practitioner, as well as nursing support and personal care.13,23 Additional therapy is provided by social workers, speech pathologists, dieticians, or podiatrists, as required.13,21,23 Case management also includes establishing community support and services for the older adult's planned discharge back to the community, as well as organizing residential aged care options, if required.13,23
In 2017–18, more than 25,000 older adults in Australia undertook TCPs either in the community or at a transition care facility, with an average length of stay of 60 days.13 Although an episode of care in a transition care facility is less costly compared to in-patient hospital care, there is limited evidence that it is more effective than a hospital episode of care in enabling older adults to successfully return to independent community living. Few studies have evaluated the health-related outcomes in older adults undertaking TCPs. A prospective observational cohort study of older adults (n = 557, median age 86 years) in Norway demonstrated that better levels of mobility and cognitive function after completing TCPs predicted successful discharge home.24 Another prospective observational study (n = 299) that evaluated the effects of TCPs on health-related outcomes also found that TCPs improved older adults’ level of cognition and physical independence.25 However, a recent randomized controlled trial (RCT) in Australia found that four extra episodes of functional exercise completed daily, in addition to standardized physiotherapy treatment, did not improve health-related outcomes or function among the 28 participants compared to the 32 participants who participated in standardized physiotherapy treatment in a transition care facility.21 Another pilot RCT (n = 35) conducted in a transition care facility in Australia evaluated whether having additional therapy assisted by a family member compared to having standardized physiotherapy improved falls-related self-efficacy and other health-related outcomes.22 This trial found that there were no between-group differences for falls-related self-efficacy or quality of life, and concluded that that it was unclear if TCPs improved health-related outcomes in older adults.22 Additionally, formal evaluation of TCPs throughout Australia has been limited to reporting one health-related outcome: performance of ADL, as measured by the Modified Barthel Index (MBI).12,26,27 In summary, there is uncertainty about whether TCPs are an effective means to improve functional ability of older adults or to increase the likelihood of their successful discharge back to independent community living, compared to usual discharge care. Hence, there is a gap in evidence for guiding best practice in the delivery of TCPs, which suggests that a systematic review is required.
A previous systematic review evaluated the evidence for the efficacy of interventions that aim to enable older adults to transition between health settings safely.28 This review found that there was weak evidence that a comprehensive care plan that delivered multifaceted interventions undertaken by health professionals reduced adverse events during the transition from hospital to home.28 However, the review did not specifically examine whether TCPs improved the rate of successful transitions from hospital to home compared to usual discharge care, improved the health of older adults who undertook such programs, or increased the proportion of older patients who were successfully discharged home compared to being admitted to residential care.28
Another systematic review, which synthesized evidence from 12 RCTs, found that some types of TCPs (discharge plans undertaken by an advanced practice nurse, self-management and transition coaching, discharge case management by a nurse, inpatient geriatric evaluation, and management) reduced rehospitalization rates compared to usual discharge care.29 However, the review found limited evidence on the effect of these TCPs on patients’ and carers’ experiences or patients’ symptom management, and no other findings on health-related outcomes were reported.29 Additionally, the studies included TCPs undertaken in different settings, namely, in hospital or at home, and other types of transitional care interventions, such as telephone follow-up, rather than being specific to TCPs being conducted in a facility setting.29
A recent systematic review synthesized evidence on the efficacy of TCPs in health service utilization in community-dwelling older adults in six countries (US, Canada, Sweden, Germany, Switzerland, and Hong Kong).30 This review found that TCP reduced hospital readmission rates, with the largest effect demonstrated at 30 days; however, the review did not examine the effects of TCP on other health-related outcomes, such as whether participants were successfully discharged home rather than admitted to RAC.30 A scoping review conducted in Canada examined the characteristics of slow-stream rehabilitation funded by government or quasi-government organizations.31 This review explored studies conducted worldwide to determine which rehabilitation models provided by the Canadian health care system were effective, whether these impacted health-related outcomes, and the discharge destination of participants.31 Findings demonstrated that participants who received rehabilitation through a TCP regained functional ability.31 However, this review did not specifically compare TCPs with other models of rehabilitation.31 Another systematic review, which synthesized evidence from two RCTs, two non-randomized controlled trials, and two pre-post observational cohort studies, found limited evidence on whether TCPs improved clinical outcomes for older adults, as there were few health-related outcomes reported in the studies that met the inclusion criteria.14 Since systematic reviews conducted to date have not specifically examined the effects of providing TCPs in facility settings on health-related outcomes, this review will contribute to the current evidence by identifying the best available evidence on the effectiveness of providing TCPs for older adults in a facility setting.
A preliminary search of the Cochrane Database of Systematic Reviews, JBI Database of Systematic Reviews and Implementation Reports, PubMed, and CINAHL (EBSCO) found no recent systematic reviews on this topic in progress. A recent systematic review registered in PROSPERO aims to evaluate the effectiveness of transitional or intermediate care interventions undertaken by older adults in any setting (home, transition care facility within RAC, hospital-based, outpatient clinical settings or tele-health) on health-related outcomes, resource use, and costs involved.32 Two other systematic review protocols have been published and these two reviews are presently being conducted.33,34 The first is a qualitative systematic review exploring older adults’ experiences when undertaking transitional care.33 The second is a scoping review that seeks to evaluate the level of patient engagement in planning and delivering interventions in TCPs.34 Neither of these reviews plan to examine physical, mental, and social health-related outcomes in older adults who undertake TCPs. Therefore, there is a gap in evidence on whether TCPs delivered in a facility setting are an effective means of improving health-related outcomes in older adults compared to usual hospital discharge care or delivering TCPs at home. Older adults have been found to consistently value being able to live independently in the community.35 However, older adults who are hospitalized are at significantly increased risk of functional decline and admission to RAC.1-5 Hence, it is important to synthesize the best available evidence on programs that improve functional outcome, avoid hospital readmissions, and lead to successful discharge home to the community. The review will seek to determine if health-related outcomes in older adults undertaking TCPs in facility settings differ significantly to providing usual discharge care or delivering TCPs in the home.
The objective of the review is to synthesize the best available evidence for the effectiveness of transition care rehabilitation programs on health-related outcomes for older adults admitted to a transition care facility.
In adults aged 65 years and older who have been discharged from hospital, what are the effects of undertaking a TCP in a transition care facility on health-related outcomes, including functional ability and discharge to independent community living, compared to usual discharge care or other rehabilitation programs?
This review will consider studies that include older adults (aged 65 years or older) undertaking a TCP. Studies that enroll participants under 65 years will be excluded, unless the mean age of participants is 65 years or older, or data are presented separately for participants 65 years or older. Studies where the population consists of participants with a range of medical or surgical conditions, including fractures, cardiorespiratory problems, mental health problems, dementia, or cognitive impairment will be eligible for inclusion. Studies will be excluded if they enroll participants receiving palliative care, or who are not undergoing rehabilitation, unless data from rehabilitation participants can be extracted separately for analysis. It has been reported that the characteristics of palliative care patients differ from those undertaking TCP36 because palliative care focuses on symptom management, with the aim of maximizing personal comfort to improve patients’ and families’ quality of life until death.36,37
For the purpose of the review, a TCP is defined as a program that provides goal-oriented care and rehabilitation in a designated transition care facility for older adults admitted directly from hospital.13,23 Studies will be excluded if they provide TCPs for older adults in their own home (in the community)38 or in an outpatient setting. This is due to differences in rehabilitation environment, mode of delivery, and staffing associated with TCPs delivered in a facility compared to those TCP delivered in the patient's home.11,38 Studies will also be excluded if they enroll only participants who have been admitted to a transition care facility to wait for RAC placement rather than undertaking a TCP. Where studies enroll both participants who are undertaking rehabilitation (TCP) and those waiting for RAC placement, they will be included if outcomes in the rehabilitation participants can be extracted and analyzed separately.
The current review will consider studies that have no comparison group, that compare TCPs to usual care, or that compare TCPs to any other rehabilitation program. Usual discharge care is defined as standard care received by older adults after discharge from hospital, such as general practitioner follow-up with or without support services at home,39 while other rehabilitation programs are defined as any program other than TCPs delivered in a facility that provides services to improve the functional capability of an older adult after hospital discharge, such as TCPs delivered in the home or other forms of rehabilitation.40 Studies will be considered for inclusion if they compare how the TCP is delivered within the facility (such as in a group setting compared to individually). Studies will also be considered for inclusion if they compare the effect of duration of the TCP, or an additional intervention to the standard TCP received in a transition facility, on health-related outcomes, such as comparing family-assisted therapy from a family member in addition to the standard TCP received in the facility.22 For example, TCPs in the UK are usually undertaken for up to six weeks, whereas TCPs in Australia are undertaken from six to 12 weeks.11,13,21
Studies will only be included in this review if they investigate health-related outcomes in older adults who complete a TCP in a facility. Health-related outcomes will be categorized according to four domains, namely, physical, cognitive, emotional, and social.26,41 For example, if a study evaluates older adults’ physical function at admission and again at discharge from a TCP using a quantitative measure such as the MBI (measures ability to complete ADL),12,26,27 this will be included.
The primary outcome of this review will be health-related outcome (social) of discharge destination (independent community living [home], permanent residential aged care, or readmission to hospital). This outcome is frequently used in rehabilitation settings as a measure of the older adult's recovery and the effectiveness of the rehabilitation setting.19-22,42,47 Secondary outcomes will be as follows: physical domain including independence in ADL, measured using the MBI12,26,27; physical outcomes (eg, walking speed measured in meters per second)44; functional mobility, measured using de Morton Mobility Index 21,43 or the Timed Up and Go Test44,45; balance, measured using the Berg Balance Scale44; emotional health outcomes (eg, depression, measured using the Geriatric Depression Scale46,47); health-related quality of life, measured using EQ-5D22,48; and cognitive ability, measured using the Mini-Mental State Examination.25,49 If studies that have evaluated other health-related outcomes using validated instruments are identified, these outcomes will be included in the review. Adverse events outcomes, if measured, will be included, such as falls prevalence or incidence, which may include rate of falls (expressed as the number of falls per 1000 person-days) or mortality.
Types of studies
This review will consider both experimental and quasi-experimental study designs, including RCTs, non-randomized trials, and observational pre-post designs. Prospective and retrospective cohort studies will be included if repeated measures are used that measure a health-related outcome before and after a TCP is delivered. This review will exclude case-control studies and single-case studies. Studies conducted in transition care facilities that examine health-related outcomes using qualitative methods will not be included. Mixed-method studies will be considered for inclusion if the relevant quantitative data can be extracted and analyzed separately.
Only studies published in English between January 1, 2000, to April 30, 2020, will be included, as TCP services commenced in 2000 in the UK and in 2004 in Australia.
The proposed systematic review will be conducted in accordance with JBI methodology for systematic reviews of effectiveness.50 This protocol has been registered with PROSPERO: CRD42020177623.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. First, an initial search of CINAHL (EBSCO) and MEDLINE (Ovid) will be undertaken using a set of key words (transition∗ care, rehabilitation, length of stay and quality of life) and relevant studies will be retrieved. These studies will be reviewed and analyzed for additional keywords using their titles and abstracts and/or Medical Subject Headings (MeSH) terms to be used for the second extended search. The search strategy, including all identified keywords and index terms, will be adapted for each included information source in the databases shown below. A proposed search strategy from the second step search for PubMed (up to April 30, 2020) is detailed in Appendix I. In the third step, the reference lists of all studies retrieved from the second stage will be hand searched for additional relevant studies not identified in steps 1 or 2.
The databases to be searched for this review include PubMed, CINAHL Plus with full text (EBSCO), AMED (Ovid), PsycINFO (Ovid), and Embase (Ovid).
Trial registry databases that will be searched are Current Controlled Trials and ClinicalTrials.gov.
MedNar, Trove (theses only), and ProQuest Dissertations and Theses databases will be searched for unpublished studies, which will also be considered for inclusion.
Following the search, all identified citations will be collated and uploaded into bibliographic software using EndNote X8.2 (Clarivate Analytics, PA, USA) or Microsoft Excel (Redmond, Washington, USA) and duplicates will be removed. Titles and abstracts will then be screened by two independent reviewers to identify studies that meet the inclusion criteria for review. Relevant studies that potentially meet the criteria will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). All full-text articles retrieved will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements between the two reviewers will be arbitrated by the third independent reviewer, if necessary. The full results of the search will be reported in the final systematic review, and both inclusion and exclusion process will be presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.51
Assessment of methodological quality
All eligible studies selected for retrieval will be assessed for methodological quality by two independent reviewers before inclusion in this review, using standardized JBI critical appraisal checklists for RCTs,50 quasi-experimental studies,50 and cohort studies,50 as appropriate. Any disagreements between the two reviewers will be resolved through discussion. If resolution is not reached, the third reviewer will be asked to mediate until mutual agreement is reached. The results of critical appraisal for methodological quality will be reported in narrative form and in a table.
Following critical appraisal, all studies regardless of methodological quality will undergo extraction and synthesis (where possible).52 This aims to ensure that the best available evidence is included in the review.
Data extraction will be performed on all included studies independently by two reviewers, using the standardized JBI data extraction tool.50 Data extracted will include details about participants and setting (including the country of the study), study design, sample size, and health outcomes measured, with data gathered for both intervention and control groups. The extraction tool will be modified to include items that describe the duration of the TCP (length of program in days), the scope of health, and medical services provided as part of the TCP, such as the frequency and nature of therapy provided (ie, daily, weekly, number of hours, amount, and type of health professional care and full-time equivalent position is used). Any disagreements that arise between two independent reviewers will be resolved through discussions before arbitration by the third reviewer. Authors of articles will be contacted to request missing or additional data for clarification, where required.
Quantitative data, where possible, will be pooled in statistical meta-analysis using Stata version 14 (Stata Corp, LLC, Texas, USA). All data will be subjected to double data entry by two independent reviewers and if discrepancies occur, the third reviewer will be asked to resolve the issue. Effect sizes will be expressed either as odds ratios (for categorical data), weighted mean differences (for continuous data) or standardized mean difference (for continuous data), with 95% confidence intervals calculated for analysis, depending on the outcome measures used in the studies.50 Odds ratios for the primary outcome will be examined to determine if there is a significant proportion (number) of older adults discharged home, compared to other settings (RAC, hospital), by undertaking a TCP in a facility setting. Where meta-analysis is possible, data will be pooled, and where there are sufficient data, sub-group analyses will be conducted to assess whether the frequency and intensity of the TCP impact the outcomes.50 Heterogeneity will be assessed using standard chi-squared and I2 tests.50 The choice of statistical model (random or fixed effects) for meta-analysis will be based on the criteria outlined previously by Tufanaru et al.53 Sensitivity analyses will be conducted to determine whether studies that have different designs (such as randomized versus non-randomized) contribute to heterogeneity or affect the pooled outcomes.50 Where pooling is not possible, data will be presented in a narrative form (tables and figures) to assist in data presentation.
A funnel plot will be generated using RevMan V5.3 (Copenhagen: The Nordic Cochrane Centre, Cochrane) to assess publication bias, if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry will be performed, where appropriate.
Assessing certainty in the findings
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach will be used for grading the certainty of evidence, and a Summary of Findings (SoF) will be created using GRADEpro (McMaster University, ON, Canada). The SoF will present the following information, where appropriate: absolute risks for the treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision, and risk of publication bias of the review results. The following outcomes will be included in the SoF: outcomes related to successful discharge (such as discharge destination or rehospitalization rate), and health-related outcomes in older adults undertaking TCPs, including physical-, emotional-, and health-related quality of life, and cognition.
This research is funded by an Australian Government Research Training Program Scholarship.
Appendix I: Search strategy
Conducted in PubMed on April 30, 2020
1. Franchi C, Nobili A, Mari D, Tettamanti M, Djade CD, Pasina L, et al. Risk factors for hospital readmission of elderly patients. Eur J Intern Med. 2013 24(1): 45–51.
2. Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc
2003; 51 (4):451–458.
3. Sager MA, Franke T, Inouye SK, Landefeld CS, Morgan TM, Rudberg MA, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med
1996; 156 (6):645–652.
4. Hoogerduijn JG, Buurman BM, Korevaar JC, Grobbee DE, de Rooij SE, Schuurmans MJ. The prediction of functional decline in older hospitalised patients. Age Ageing
2012; 41 (3):381–387.
5. Kleinpell RM FK, Jennings BM. Reducing functional decline in hospitalized elderly. In: Hughes, RG, editor. Patient safety and quality: an evidence-based handbook for nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008.
6. Australian Institute of Health and Welfare. Older Australia at a glance [Internet]. 2018 [cited 2019 Jun 30]. Available from: https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/notes
7. Australian Institute of Health and Welfare. Movement between hospital and residential aged care 2008-2009 [Internet]. 2013 [cited 2019 Nov 20]. Available from: https://www.aihw.gov.au/reports/aged-care/movement-between-hospital-and-residential-aged-car/contents/table-of-contents
8. Australian Institute of Health and Welfare. Older people leaving hospital: a statistical overview of the transition care program 2009-10 and 2010-11 [Internet]. 2012 [cited 2019 Nov 20]. Available from: https://www.aihw.gov.au/reports/aged-care/older-people-leaving-hospital-2009-10-2010-11/data
9. Fong JH, Mitchell OS, Koh BSK. Disaggregating activities of daily living limitations for predicting nursing home admission. Health Serv Res
2015; 50 (2):560–578.
10. Griffiths PD, Edwards MH, Forbes A, Harris RL, Ritchie G. Effectiveness of intermediate care in nursing-led in-patient units. Cochrane Database Syst Rev
11. Young J, Gladman JR, Forsyth DR, Holditch C. The second national audit of intermediate care. Age Ageing
2015; 44 (2):182–184.
12. Australian Government Department of Health. Ageing and aged care: national evaluation of the transition care program full report 2008 [Internet]. 2015 [cited 2019 Nov 20]. Available from: https://studylib.net/doc/7108960/national-evaluation-of-the-transition-care-program
13. Australian Government Department of Health. Transition care programme [Internet]. 2020. [cited 2019 May 20]. Available from: https://www.health.gov.au/initiatives-and-programs/transition-care-programme
14. Toles M, Colon-Emeric C, Asafu-Adjei J, Moreton E, Hanson LC. Transitional care of older adults in skilled nursing facilities: a systematic review. Geriatr Nurs
2016; 37 (4):296–301.
15. Parsons M, Senior HEJ, Kerse N, Chen M-H, Jacobs S, Vanderhoorn S, et al. The assessment of services promoting independence and recovery in elders trial (ASPIRE): a pre-planned meta-analysis of three independent randomised controlled trial evaluations of ageing in place initiatives in New Zealand. Age Ageing
2012; 41 (6):722–728.
16. Jacobs S, Baird J, Parsons M, Sheridan N. Southern District Health Board: a model of care that intergrates health and support services in the community for the older person: final report [Internet]. 2011 [cited 2019 Nov 20]. Available from: https://www.southerndhb.govt.nz/files/20110921142336-1316571816-1.pdf
17. Senior HEJ, Parsons M, Kerse N, Chen M-H, Jacobs S, Hoorn SV, et al. Promoting independence in frail older people: a randomised controlled trial of a restorative care service in New Zealand. Age Ageing
2014; 43 (3):418–424.
18. Leung G, Katz PR, Karuza J, Arling GW, Chan A, Berall A, et al. Slow stream rehabilitation: a new model of post-acute care. J Am Med Dir Assoc
2016; 17 (3):238–243.
19. Nakanishi M, Shindo Y, Niimura J. Discharge destination of dementia patients who undergo intermediate care at a facility. J Am Med Dir Assoc
2016; 17 (1):92e1–92e7.
20. Morita K, Ono S, Ishimaru M, Matsui H, Naruse T, Tasunaga H. Factors affecting discharge to home of geriatric intermediate care facility residents in Japan. J Am Geriatr Soc
2018; 66 (4):728–734.
21. Parker C, Hill K, Cobden J, Davidson M, McBurney H. Randomized controlled trial of the effect of additional functional exercise during slow-stream rehabilitation in a regional center. Arch Phys Med Rehabil
2015; 96 (5):831–836.
22. Lawler K, Shields N, Taylor NF. Training family to assist with physiotherapy for older people transitioning from hospital to community: a pilot randomized controlled trial. Clin Rehabil
2019; 33 (10):1625–1635.
23. Government of Western Australia Department of Health. Healthy WA: Transition care program (TCP) [Internet]. [updated Feb 2019; cited 2019 Nov 20]. Available from: https://healthywa.wa.gov.au/Articles/S_T/Transition-Care-Program-TCP
24. Abrahamsen JF, Haugland C, Nilsen RM, Ranhoff AH. Predictors for return to own home and being alive at 6 months after nursing home intermediate care following acute hospitalization. Eur Geriatr Med
2014; 5 (2):108–112.
25. Fiorini G, Pandini S, De Matthaeis A, Seresini M, Dragoni R, Sfogliarini R. Intermediate care as a means of improving mental status in post-acute elderly patients. Aging Clin Exp Res
2013; 25 (3):337–341.
26. Quinn TJ, McArthur K, Ellis G, Stott DJ. Functional assessment in older people. BMJ
27. Hsieh YW, Wang CH, Wu SC, Chen PC, Sheu CF, Hsieh CL. Establishing the minimal clinically important difference of the Barthel Index in stroke patients. Neurorehabil Neural Repair
2007; 21 (3):233–238.
28. Mansah M, Fernandez R, Griffiths R, Chang E. Effectiveness of strategies to promote safe transition of elderly people across care settings. JBI Database Syst Rev Implement Rep
2009; 7 (24):1036–1090.
29. Allen J, Hutchinson A, Brown R, Livingston P. Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review. BMC Health Serv Res
30. Weeks LE, Macdonald M, Martin-Misener R, Helwig M, Bishop A, Iduye DF, et al. The impact of transitional care programs on health services utilization in community-dwelling older adults: a systematic review. JBI Database System Rev Implement Rep
2018; 16 (2):345.
31. Maximos M, Seng-iad S, Tang A, Stratford P, Bello-Haas VD. Slow stream rehabilitation for older adults: a scoping review. Can J Aging
2019; 38 (3):328–349.
32. Sezgin D, Hendry A, Carriazo AM, Lopez-Samaniego L, Arnal C, Rodriguez-Acuna R. Effectiveness of transitional or intermediate care interventions for older adults: a systematic review (registered 2019) [Internet]. PROSPERO National Institute for Health Research (NIHR) PROSPERO. 2019 CRD42019122982. [cited 20 Nov 2019]. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019122982
33. Høy B, Ludvigsen M. Older adults’ experiences of patient involvement in transitional care: a qualitative systematic review protocol. JBI Database System Rev Implement Rep
2018; 16 (4):860–866.
34. Ludvigsen MS, Hoy B. Patient involvement interventions for older adults in transitional care between hospital and primary care: a scoping review protocol. JBI Database System Rev Implement Rep
2018; 16 (4):871–884.
35. van Leeuwen KM, van Loon MS, van Nes FA, Bosmans JE, de Vet HCW, Ket JCF, et al. What does quality of life mean to older adults? A thematic synthesis. PLoS One
2019; 14 (3):e0213263.
36. Runacres F, Gregory H, Ugalde A. Restorative care for palliative patients: a retrospective clinical audit of outcomes for patients admitted to an inpatient palliative care unit. BMJ Support Palliat Care
2016; 6 (1):97–100.
37. Kanach FA, Brown LM, Campbell RR. The role of rehabilitation in palliative care services. Am J Phys Med Rehabil
2014; 93 (4):342–345.
38. King AI, Parsons M, Robinson E, Jorgensen D. Assessing the impact of a restorative home care service in New Zealand: a cluster randomised controlled trial. Health Soc Care Community
2012; 20 (4):365–374.
39. Health Direct. Hospital discharge planning [Internet]. 2019 [cited 2019 Sep 21]. Available from: https://www.healthdirect.gov.au/hospital-discharge-planning
40. Australian Government. My aged care: short-term care [Internet]. [cited 2019 Sep 21]. Available from: https://www.myagedcare.gov.au/short-term-care
41. Rubenstein LZ. Geriatric assessment technology: The state of the art. New York: Springer; 1995.
42. Luker JA, Bernhardt J, Grimmer KA, Edwards I. A qualitative exploration of discharge destination as an outcome or a driver of acute stroke care. BMC Health Serv Res
43. de Morton NA, Davidson M, Keating JL. The de Morton Mobility Index (DEMMI): an essential health index for an ageing world. Health Qual Life Outcomes
44. Steffen TM, Hacker TA, Mollinger L. Age- and gender- related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Phys Ther
2002; 82 (2):128–137.
45. Yeung TSM, Wessel J, Stratford P, Macdermid J. The Timed Up and Go Test for use on an inpatient orthopaedic rehabilitation ward. J Orthop Sports Phys Ther
2008; 38 (7):410–417.
46. Dennis M, Kadri A, Coffey J. Depression in older people in the general hospital: a systematic review of screening instruments. Age Ageing
2012; 41 (2):148–154.
47. Abrahamsen JF, Haugland C, Nilsen RM, Ranhoff AH. Three different outcomes in older community-dwelling patients receiving intermediate care in nursing home after acute hospitalization. J Nutr Health Aging
2016; 20 (4):446–452.
48. Leon-Salas B, Ayala A, Blaya-Novakova V, Avila-Villanueva M, Rodriguez-Blazquez C, Rojo-Perez F, et al. Quality of life across three groups of older adults differing in cognitive status and place of residence. Geriatr Gerontol Int
2015; 15 (5):627–635.
49. Creavin ST, Wisniewski S, Noel-Storr AH, Trevelyan CM, Hampton T, Rayment D, et al. Mini-mental state examination (MMSE) for the detection of dementia in clinically unevaluated people aged 65 and over in community and primary care populations. Cochrane Database Syst Rev
50. Aromataris E, Munn Z, editors. JBI Reviewer's Manual [Internet]. Adelaide: JBI, 2017 [cited 2019 Apr 20]. Available from: https://reviewersmanual.joannabriggs.org/
51. Moher D, Liberati A, Tetzlaff J, Altman DG. the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med
2009; 6 (7):e1000097.
52. Bown MJ, Sutton AJ. Quality control in systematic reviews and meta-analyses. Eur J Vas Endovasc Surg
2010; 40 (5):669–677.
53. Tufanaru C, Munn Z, Stephenson M, Aromataris E. Fixed or random effects of meta-analysis? Common methodological issues in systematic reviews of effectiveness. Int J Evid Based Health
2015; 13 (3):196–207.