Table 3 Transitional care delivery

Benzo et al., 2019

Health coaching is delivered in person for the first meeting and then by telephone calls once a week for the first three months and then once a month. The health coaching goal was to instruct patients on self-management activities.

Transition planning; Patient and family education; Timely and appropriate follow-up; Information transfer

Patients received the usual care based on the guideline

Cleland et al., 2005

Two interventions: home telemonitoring (patients were instructed on how to record daily parameters) and nurse telephone calls (consisting of monthly calls to patients by an expert nurse).

Timely and appropriate follow-up; Information transfer

Patients received their management plan and forwarded it to their general practitioner for implementation.

Daly et al., 2005

Case management by an advanced-practice nurse. Predischarge hospital evaluation for establishing a care plan after disenrollment. After discharge, the nurse visited the patient in person or by telephone consisting of emotional support, counseling, arranging follow-up visits and monitoring the patient’s condition. The intervention lasted two months.

Transition planning; Patient and family education; Timely and appropriate follow-up; Information transfer

By the time patients and family members in the usual care group asked the interviewers for advice or information, they were referred to their general practitioner, the staff of the extended care facility or the home care agency.

Goldberg et al., 2003

Telemonitoring intervention. Patients were instructed on how to record daily parameters (weight, heart failure symptoms). A physician checked the parameters reported and contacted the patient as necessary.

Medication management; Transition planning; Timely and appropriate follow-up; Information transfer

Standard outpatient therapy for heart failure, including the recommendation to use a standard scale for daily weight assessment.

Hanson et al., 2019

Transitional care intervention consisted in predischarge palliative care consultation, plus 2-week post-discharge transitional

telephone support by a palliative care nurse practitioner. Intervention included the delivery of information and supportive calls at 72 h and two weeks post-discharge.

Transition planning; Patient and family education; Timely and appropriate follow-up; Information transfer

Control groups dyads received the routine of care and educational information.

Naylor et al., 2004

Nurse visits during hospitalizations, aiming at orienting and training heart failure patients during the acute phase and identifying specific care plans based on the patient’s condition. Then, after discharge, the intervention consisted in nurse home visits for three months and telephone availability to address patient’s needs

Transition planning; Timely and appropriate follow-up;

Discharge planning was a collaborative effort involving the attending physician, the primary care nurse and the discharge planner. Hospitals followed established discharge policies. Similarly, primary home care sites followed standardized procedures, including facilitation of referrals, availability of comprehensive home care and 24/7 nursing access.

Ng AYM et al., 2017

Post-discharge home visits and telephone calls delivered by palliative care nurses case managers and consisting of physical and psychological symptoms assessment and management, social support, spiritual and existential aspects of care, setting goals of care, and discussion of treatment preference at end-of-life stage.

Transition planning; Timely and appropriate follow-up; Information transfer

Both the intervention and control group received standard discharge planning. If necessary, episodic, unstructured home care was organized for patients at the time of discharge. The comparison group received two social calls.

Nordly et al., 2018

A psychological intervention based on existential-phenomenological therapy targeted towards the dyad. Patients and informal caregivers had two sessions at home after discharge with a psychologist within the first month followed by needs-based interventions.

Transition planning; Patient and family education; Timely and appropriate follow-up; Patient and family participation; Information transfer

Patients could be referred, at the discretion of the oncologist or another physician, to specialized palliative care. Standard care includes inpatient and outpatient care, access to a general practitioner, out-of-hours GP service, psychological counseling and access to 24-hour home care.

Rogers et al., 2017

The intervention was performed by a nurse practitioner and focused on shared goal-setting amelioration and palliative care goals. Following hospital discharge, the nurse practitioner actively participated in the ongoing management of the patients in the outpatient environment.

Transition planning; Timely and appropriate follow-up; Information transfer

Patients were managed by a team of cardiologists experienced in HF.

Smith et al., 2014

A pedagogical educational intervention consisting of group appointments where patients were educated on how to record daily parameters (weight, fluid/sodium intake, physical activity, emotions and moods, and heart failure symptoms).

Transition planning; Timely and appropriate follow-up; Information transfer

Patients received both standard care and HF self-management videos on DVD.

Vianello et al., 2016

Telemonitoring with a finger pulse oximeter

Transition planning; Timely and appropriate follow-up;

Participants in the two groups received the same clinical care and had access to the same health services.

Wang et al., 2013

Predischarge nursing education was put in place until the conditions were stable. After discharge, telephone follow-up for four weeks followed by home follow-ups at three and six months consisting of interventions based on the health belief model (HBM) were delivered.

Transition planning; Timely and appropriate follow-up; Information transfer

On the day of discharge, both intervention and control group patients received an educational manual and a follow-up sheet with additional materials.

Wong et al., 2016

Predischarge assessment followed by telephone or home visit follow-up. The follow-ups were delivered weekly for the first month, then monthly for the following 12 weeks.

Transition planning; Timely and appropriate follow-up; Information transfer

The control group received placebo calls, which consisted of light conversations unrelated

Hernandez-Quiles et al., 2024

In the TELECARE arm, patients received the same care as UCARE but with the addition of synchronous monitoring technology. This allowed for real-time data submission and continuous monitoring by the healthcare team. Automated alerts for data variations were sent to Salud Responde, mirroring the UCARE response. Automatic alerts for data changes were sent to Salud Responde, following UCARE’s response. Both arms maintained regular medical follow-ups with additional trial-specific visits to monitor progress and adjust care.

Transition planning; Timely and appropriate follow-up; Information transfer

In the UCARE arm, patients adhered to a standard care protocol that emphasized self-care and included manual tracking of key bio-parameters like blood pressure and blood glucose in a paper notebook. They were taught to recognize exacerbation signs through clinical questionnaires and received educational materials. The Salud Responde call-center was available on demand to manage clinical incidents or bio-parameter changes, providing necessary interventions or activating emergency services based on the assessed severity.

Bernard et al., 2019*

During hospitalization, patients in the intervention arm receive information material and comprehensive palliative care consultations by a palliative care physician or nurse, in addition to standard liver care. Telephone contact takes place according to a flexible schedule tailored to the patient’s needs (at least once a month).

Transition planning; Timely and appropriate follow-up; Information transfer

Patients in the usual care arm do not receive consultations with the palliative care service, but the consultation may be requested by the patient, the family or the attending physician. These consultations include the same palliative care services as the intervention arm, except for patient information material and telephone consultations.

Griffin et al., 2023*

Every day the study nurse meets the caregiver until the patient is discharged from the hospital. The caregiver receives an iPad upon discharge and has an initial video call with the study nurse within 24–48 h of discharge from the hospital and then weekly for 8 weeks.

Transition planning; Patient and family education; Timely and appropriate follow-up; Patient and family participation; Information transfer

In the patient’s usual arm of care, the physician and nursing staff, with input from the palliative care service, help the caregiver to develop a plan for the patient’s discharge and to care for the patient upon discharge. After discharge from hospital, a member of the study team calls the caregiver once a month for the duration of the study.