Discussion

This systematic review presents the effects of TCi on quality of care, clinical outcomes and healthcare services use outcomes among older adults transferring from the acute care to the LTCF setting. Medications problems (quality of care), hospital readmission and ED visits (healthcare services use) and hospital days (healthcare services use) were the most documented outcomes, with data from six, six and five studies respectively. The reported results were however inconsistent. Medications problems as an outcome seemed nevertheless to hold the most promising results, with four individual studies out of six reporting significantly favorable results with TCi.12,16,27,28Additionally, high levels of satisfaction were achieved with TCi.
Our results show that medications problem outcomes are the most likely to be reported as benefiting from TCi. Indeed, medications problems could represent an important target to improve care during transitions from acute care to LTC. More studies investigating more closely this outcome would be needed to confirm these results. Yet, previous studies reported that adverse drug events attributable to medication changes occur in 20% of patients going from acute care to LTC,31 with medication errors occurring during these transitions as being most harmful to patients.32 In the context where information gaps are reported in over 85% of transfers between ED and LTC,33 this suggests that medications problems might be addressed by improving communication. Indeed, all four interventions where the situation improved significantly involved a specific discharge summary or communication form sent to the LTC setting before or at the time of patient transfer. These interventions further emphasized the importance of medication clarification, either through a formal medication reconciliation16,27,28 or via completion and transmission of a discharge prescriptions form.12 It is worth noting that these four studies also involved a pharmacist as key healthcare professional in carrying out the intervention.12,16,27,28 Of the studies where no effect was reported, one used fax as a communication strategy,18 and important concerns have been raised about the use of this technology.34 The other was a quality improvement pilot study that was possibly insufficiently powered to detect a significant change (10 patients in each group). The authors of this pilot study raised the issue of a possible unsuccessful implementation of the intervention and important group differences, notably in their health status and medication orders patterns.20
Our results further suggested that increased communication between hospitals and LTC, including medication reconciliation or specific transfer forms, was not enough to decrease healthcare services use (hospital readmission and ED visits, hospital days). In this regard, the timing of the communication might be a key element to consider. Indeed, the recommendations to improve transitional care were not only to increase the communication per se but rather to “facilitate the timely transfer of essential information across settings”.7In the case of the acute care to LTCF transition, this “timely” criterion could translate into the early transmission of the medications list before discharge, to ensure that the medications are ready to be administered upon patient’s arrival and to avoid delayed doses.12 This would further allow LTCF’s physicians time to review the patients’ chart and status at an appropriate time rather than through an urgent visit or via a locum tenens.12
Among the frail population residing in LTC, transfers to the acute care setting are challenging and stressful life events.8This is especially true for cognitively impaired patients,35 who constitute between 45-84% of the LTC population.1,36 To address this issue, upstream interventions aiming to reduce potentially avoidable transfers to acute care are warranted.8,37 Admissions to acute care, however, cannot always be prevented, and may continue to represent a part of the care trajectory for some patients,13,14with a 2000 study suggesting that 60% of hospital admissions are necessary and recommended.15 As part of quality improvement initiatives, several LTCFs worldwide have implemented interventions to reduce potentially avoidable hospital admissions,38 and TCi between these two care settings remain a highly relevant research area. The characteristics and particular components of impactful and efficient TCi in this specific context are still to be determined.
Our study also highlights the high levels of satisfaction reported by patients, caregiver and physicians with TCi. Enhanced continuity of care associated with TCi is particularly valued by older vulnerable patients, and can foster a strong foundation for a better communication with patients, and caregivers. It can also result in a greater sense of security and trust in the healthcare system overall.39In our review, the three studies reporting high satisfaction involved either phone calls or in-person support and sharing of information.12,29,30 Additionally, gaps in information exchange during transitions resulting in missing data from the medical charts of transferred patients can lead to frustration, increased work-stress and feelings of inadequacy and guilt among healthcare professionals working in LTC.10 TCi focusing on improving inter-facility communication are therefore also warranted.
This review has many strengths, starting with its systematic design and exhaustive literature search. Another strength is the fact that we focused specifically at TCi for older patients transitioning from acute care to LTC setting. Our review’s principle limitation stems from heterogeneity in both the outcomes reported from each study and in the various tools used as interventions. This prevented us from conducting a meta-analysis and pooling results, but it did allow for a narrative synthesis that provides a rich and in-depth overview of the available relevant literature. Our study also suffered from a paucity of eligible articles in our sample. We identified only 11 studies, among which only 2 were randomized trials, whereas reviews reporting on TCi in other settings are usually much larger, with some reporting on up to 92 studies.22 Our small sample also limited our pooling possibilities and further highlights the need for more TCi studies targeting transfers to the LTC setting. Lastly, our sample quality appraisal MMAT scoring revealed reporting issues among several studies in our sample, with 4 studies receiving at least one negative MMAT item response, and a total of 7 where it was unclear whether or not an MMAT criterion was satisfied. P-values were also not routinely reported.
Future studies should aim to report standardized outcomes and their related p-values, using validated and relevant indicators to facilitate the pooling of data. Authors should also strengthen their efforts towards higher quality of reporting.

Conclusions and implications

TCi targeting older adults being transferred from acute care to the LTC setting aim to improve the transitions for the most vulnerable among the geriatric population.1 Our review, however, was able to identify only a limited number of relevant studies, in spite of conducting an exhaustive search, and found that the literature is fraught with inconsistent results. In the identified interventions, a focus on medication reconciliation and timely intra-institutional communication appear to be important components that improve the acute care to LTCF transitions in this population. Future research should include well-designed large-scale TCi using standardized and validated outcome measures in order to improve our understanding of the effects of TCi on LTC patients being discharged from acute care.