The Impact of Transitional Care for Geriatric Patients with Chronic Diseases

Abstract

Indonesia has gradually become an aging society as socio-demographic changes happen in the last decades, affected the health care system in many countries. An increased hospital readmission rate and prolonged hospitalization in elderly patients due to chronic illness have been a new challenge. A comprehensive plan to ensure the coordination and continuity of health care after hospital discharge is needed to improve the sustainability of long-term management. In 2021, literature was searched on the PubMed, ScienceDirect, and Cochrane electronic databases with keywords for transitional care, geriatric, and chronic disease. Inclusion criteria were randomized controlled trial (RCT), systematic review, or meta-analysis studies that implemented transitional care intervention (TCis) for people older than 60 with chronic diseases. Studies were limited to those published in the past ten years and published in Bahasa/English. Critical appraisal was assessed using the PRISMA guideline. We identified 107 records. Seven articles met the inclusion criteria. Outcome assessments were conducted from one to 12 months after discharge. TCis were divided into 3 points: before discharge, after discharge at home, and throughout the entire period. Readmission was measured in most studies (n=7), mortality (n=4), and emergency department (ED) visit (n=3). Most of the study showed a positive impact in the intervention groups (IG) compared to the control groups (CG). Transitional care is beneficial for geriatrics with chronic disease as it reduces hospital readmission rates, mortality, and ED visit. Five domains should be addressed to have effective transitional care: comprehensive assessment, planning and communication, support for self-care and the caregiver, access facilitation, and a competent healthcare team.