In 1947, The Joint Commission, a US organization that accredits health care organizations, initially proposed the concept of transitional care (TC), which emphasizes that continuity of care should not be disrupted even after hospitalized patients return home.1 Discharging patients from a hospital has been challenging for global health care systems, especially for older adults who often need more time to reach full recovery due to chronic health conditions.2 Older adults confront many transitions in care within and across health care settings and experience difficulties navigating complex and fragmented health systems.3,4 This results in inconsistent care and adverse incidents after discharge.5 Rather than discharge planning occurring solely within the acute inpatient setting, holistic TC interventions involving pre-hospital discharge, immediate, and post-hospital discharge activities at home are recommended for older adults.6 Older adults are also assumed to have a greater demand for family caregiving, and these demands are becoming more significant in the context of the global population aging and the global shortage of health care providers.7 Thus, family members are required to become involved in providing care for older patients throughout hospitalization and returning home.8
Several studies indicate that involving patients and families in TC provides better health outcomes for patients and family caregivers.9,10 These outcomes include better patient safety, lower readmission rates, less stress, less caregiver burden, and greater well-being of both patients and family caregivers.8,11,12 Family involvement has the potential to improve the quality of care that patients and family caregivers receive from health care providers by developing respect, effective collaboration, and better support.13,14 Family members were previously only involved in the decision-making for a patient's TC.15 Today, family caregivers are also being included as partners in the TC team. This involves participation in medication management, discharge care planning, patients’ self-monitoring, and sharing information.16,17 However, family involvement is limited during TC because many health care providers report a lack of competencies, including communication skills and conflict management,8,18 resulting in failing to address family caregivers’ needs during transition from a hospital to home.19 Thus, family caregivers have reported negative experiences during TC, such as uncertainty about care coordination, ambiguous roles and obligations, diluted personal ownership over care, and role pressure due to system constraints.20-22 Consequently, after hospital discharge, patients experience clinical deterioration, unplanned health care use (eg, early return to acute care), and even death. Further, patients and family caregivers experience low satisfaction with care due to a lack of congruence between patient–caregiver preferences and care services.23,24
A preliminary search of PROSPERO, the Cochrane Database of Systematic Reviews, JBI Evidence Synthesis, MEDLINE, and CINAHL was conducted and a small number of systematic reviews and systematic review protocols on the topic was identified. For example, in 2014, Allen et al.25 conducted a systematic review to examine the quality of TC interventions for older people in reducing rehospitalization and length of stay; however, this study was not limited to family involvement interventions. In 2017, Rodakowski et al.17 conducted a meta-analysis to explore family integration during transition from hospital to home for older adults. The study found that discharge planning interventions with caregiver integration were associated with fewer readmissions; however, the study focused only on the discharge period, and not the entire transition to home period.17 In 2018, Høy and Ludvigsen developed protocols to conduct a qualitative systematic review to explore older adults’ experiences in patient involvement in TC,26 and a scoping review to describe patient involvement interventions for older adults in TC.27 These review protocols focused on how families are involved in TC, their involvement preferences, and key issues encountered by health care providers when involving family caregivers. However, the effects of family involvement in TC interventions were not explained. In 2019, Murray et al. conducted a qualitative systematic review and created a model to explain the experiences of older people in care involvement during transition from hospital to home.28 This review revealed types of involvement—mostly in the information-sharing process during the TC with usual care—and not experiences related to TC interventions.
Broader analysis is required to synthesize and integrate qualitative and quantitative data about the effectiveness of family involvement in TC and their experiences within the TC process. The proposed review will systematically examine published quantitative and qualitative data to provide a better understanding of how families are involved, their specific roles, ways to effectively involve them, the impacts of this form of TC on families’ health and well-being as well as health care providers’ satisfaction. The review will also explore the positive and negative experiences of families and health care providers during family involvement in TC. This review will establish a knowledge base for developing an effective, integrated family caregiver intervention in TC from hospital to home.
- i) What are the effects of family involvement in TC interventions on older patients, family caregivers, and health care providers?
- ii) How do older patients, family caregivers, and health care providers experience family involvement in TC?
This review will consider studies that include people with experience of family involvement in a TC intervention. The participants will include patients who are 60 years and older without cognitive impairment, their family caregivers, or health care providers (doctor, nurses, and others).
Phenomena of interest
The quantitative component of this review will consider studies that evaluate the effectiveness of family involvement in TC interventions for older patients from hospital to the patient's home. The interventions must include family caregiver participation in pre-hospital discharge, immediate, and post-hospital discharge activities. The family involvement interventions can be person-centered care, patient-centered care, resident-centered care, client-centered care, family-centered care, patient/family engagement, caregiver integration in care, patient involvement in care, clinician–patient communication, patient and caregiver partners, collaborative care, and patient empowerment.
The qualitative component of this review will consider studies that explore the experiences of older patients, family caregivers, or health care providers about family involvement interventions in TC.
The quantitative component of this review will consider studies that compare family involvement interventions that include family participation in TC, with standard care or other TC interventions.
The quantitative component of this review will consider studies that include at least one of the outcomes listed below. For older patients, the primary outcomes will be: i) readmission rates, ii) number of emergency department visits, iii) functional ability assessed by measurements such as the Barthel index, and iv) quality of life as assessed by measurements such as the 36-Item Short Form Survey. The secondary outcomes will be: i) knowledge and understanding, ii) satisfaction, and iii) discharge readiness assessed by measurements such as Readiness for Hospital Discharge Scale. For family caregivers, the primary outcomes will be: i) caregiver strain assessed by measurements such as the Caregiver Strain Index, ii) caregiver stress assessed by measurements such as the Perceived Stress Scale, iii) caregiver burden assessed by measurements such as the Caregiver Burden Inventory, iv) quality of life assessed by measurements such as the 36-Item Short Form Survey, and v) care readiness assessed by measurements such as the Preparedness for Caregiving Scale. The secondary outcomes will be: i) knowledge and understanding, ii) self-efficacy assessed by measurements such as the Scale for Caregiving Self-Efficacy, and iii) satisfaction. For health care providers, the primary outcome will be satisfaction with the TC model that may be assessed by questionnaires, such as the Physician-PREPARED scale, physicians’ ratings of satisfaction, and a 100-mm visual analogue scale. However, if other measurements are found, the authors will also consider including them in the study.
The qualitative component of this review will consider studies investigating the experiences of older patients or health care providers participating in family involvement interventions in the TC from any inpatient hospital ward to the patient's home. Other types of TC will be excluded from this study.
Types of studies
For the quantitative component, this review will consider both quantitative and mixed methods studies with experimental and quasi-experimental designs, including randomized controlled trials, quasi-experimental studies, interrupted time-series studies, and uncontrolled before-after studies. The quantitative component of the review will also consider prospective and retrospective cohort studies and analytical cross-sectional studies. The qualitative component of this review will consider studies that may use different qualitative methodologies, such as phenomenology, grounded theory, ethnography, and action research. Additionally, mixed methods studies will be included if data from the quantitative and qualitative components can be extracted separately.
The proposed systematic review will be conducted in accordance with the JBI methodology for mixed methods systematic reviews.29 This review has been registered in PROSPERO (CRD42020191464).
To identify both published and unpublished studies, a three-step search strategy will be followed. An initial limited search of MEDLINE and CINAHL was undertaken. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE (PubMed; see Appendix I). Potential preliminary keywords include “transitional care∗,” “discharge care planning∗,” with “aged ∗,” “caregivers∗” with “family engagement∗” with “family participation∗,” “family integration∗,” “person-centered care∗,” and “patient-centered care.∗” The search strategy, including all identified keywords and index terms, will be adapted for each included information source. Thirdly, the reference lists of all included reports and articles will be searched for additional studies.
The review will consider studies in English or Thai published from 1989 to the present. The search will commence in 1989, when the first TC model was developed.30
The following databases will be searched for published studies: CINAHL Plus with Full Text (EBSCO), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), Primary Health Care Research and Information Service, Scopus, Embase (Elsevier), Web of Science, ScienceDirect, PsycINFO (APA), Health Source: Nursing/Academic Edition, ASEAN Citation Index (ACI), and Thai Journals Online (ThaiJO). The search for unpublished studies will include OpenGrey, Google Scholar, MedNar, and ProQuest Dissertations and Theses Global.
Following the search, all identified citations will be collated and uploaded into RefWorks (ProQuest LLC, Ann Arbor, USA), and duplicates removed. Two independent reviewers will screen titles and abstracts for assessment against the inclusion criteria. Potentially relevant studies that meet the inclusion criteria will be retrieved in full and their details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).31 The full text of selected citations will be retrieved and assessed in detail against the inclusion criteria by two independent reviewers. Included studies will undergo a process of critical appraisal. Full-text studies that do not meet the inclusion criteria will be excluded, and reasons for exclusion will be provided in an appendix in the final systematic review. Disagreements between the reviewers at each stage of the selection process will be resolved through discussion or with a third reviewer. The study selection process will be fully reported in the final report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.32
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers at the study level for methodological quality using the standardized critical appraisal instruments from JBI. Quantitative papers will be assessed using JBI's critical appraisal tools for each design,33 such as the JBI critical appraisal checklist for quasi-experimental studies and the JBI critical appraisal checklist for randomized controlled trials. Qualitative papers will be assessed using the JBI critical appraisal checklist for qualitative research.34 Mixed methods studies will be assessed by two independent reviewers for information on each component, as found in JBI SUMARI.
Once all studies have been appraised, studies with scores below 60% will be excluded, as suggested by JBI.35 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The results of critical appraisal will be presented in a narrative format as well as in a table.
Quantitative data from quantitative studies and the quantitative parts of mixed method studies will be extracted by two independent reviewers using the standardized JBI data extraction tool in JBI SUMARI. The extracted data will include specific details relevant to the review question and objectives, including the publication details, participants, setting, study design, family involvement in activities, outcome measures, statistical analysis, and results (eg, grouped according to older patients, family caregivers, or health care providers).
Qualitative data from qualitative studies and the qualitative parts of mixed method studies will be extracted by two independent reviewers using the JBI qualitative data extraction tool. The extracted data will include specific details relevant to the review question and objectives, including populations (eg, patients, family caregivers, health care providers), methods, phenomena of interest (eg, attitudes, perceptions, and experiences), settings, and cultural contexts.
Authors of both quantitative and qualitative primary studies will be contacted if there are missing information or data that need clarification.
Data synthesis and integration
This review will follow a convergent segregated approach to synthesis and integration according to the JBI methodology for mixed methods systematic reviews using JBI SUMARI. This will involve separate quantitative and qualitative synthesis followed by integration of the resultant quantitative evidence synthesis and qualitative evidence synthesis.
For quantitative synthesis, studies will, where possible, be pooled with statistical meta-analysis using JBI SUMARI. Effect sizes will be expressed as either odds ratios (for dichotomous data) or weighted (or standardized) final post-intervention mean differences (for continuous data). The 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard χ2 and I2 tests. The choice of model (random or fixed effects) and method for meta-analysis will be based on the guidance of Tufanaru et al.36 Subgroup analyses will be conducted where there are sufficient data to investigate family involvement in different care activities. Sensitivity analyses will be conducted to test decisions made regarding methodological quality. Where statistical pooling is not possible, the findings will be presented in narrative format, including tables and figures, to aid data presentation. A funnel plot will be generated to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test, Begg test, Harbord test) will be performed where appropriate.
For qualitative synthesis, studies will, where possible, be pooled using JBI SUMARI using the meta-aggregation approach.34 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings based on similarity in meaning. These categories will then be subjected to a synthesis to produce a comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative format.
To integrate quantitative and qualitative evidence, the findings of each single-method synthesis included in this review will be configured according to the JBI methodology for mixed methods systematic reviews.29 This will involve quantitative and qualitative evidence being juxtaposed and then linked into a line of argument to produce an overall configured analysis. Where configuration is not possible, the findings will be presented in narrative format.
This review will be undertaken as part of author ST's PhD program (nursing) at Florida Atlantic University.
Appendix I: Search strategy
Search conducted October 6, 2021. Records retrieved: 169.
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