Interprofessional Teams Supporting Care Transitions from Hospital to Community: A Scoping Review

Early supported discharge.^10,13

Home-based time limited rehabilitation post hospitalization.^13,16,33

Post-discharge outpatient transitional clinic.^9,19,36

Transitional/mobile team- care is provided where the older adult is situated.^10,13

Hospital in-reach. A community team member visits the hospital pre patient discharge.^1,10

• Hospital out-reach. A member(s) of the hospital team continues to provide service post-discharge.^{2,7,12,16,17,18,26,27,33}

Bridging team member who provides care both in hospital and in community.^2,14,26

Post-discharge care access. The older adult can access care from the hospital team after discharge.^10,17

Clear roles/tasks for each team member.^{9,10,12,14,16,22,32,36}

Ensure clear understanding of responsibilities of each team.^22,34

Consistent patient care meetings on daily or weekly basis.^5,7,8,22,32

Consistent administrative meetings.²²

Team develops the program/intervention.^12,19

Mechanisms are in place to ensure quality improvement in care delivery.^19,22

Professional education that promotes interprofessional and/or inter-agency learning.^1,32,34

Sharing of activities and duties between hospital and community organizations.^22,35

Philosophy that community teams are a part of hospital team even though not physically present.²⁴

Employ team collaboration strategies in meetings.^8,24

Geriatric comprehensive assessment^5,17,34

Interprofessional team care planning

• Hospital care plan.^2,30

• Discharge planning.^22,26

• Post-hospital care plan.^1,5,17

Home visits

• Joint home visits pre-discharge with both community and the hospital teams.^4,5,10

• Post-discharge home visit by community team.⁵

• Post-hospital team visit by hospital team.¹⁷

Post-discharge monitoring

• Phone intervention.^7,19,26

Remote data monitoring.⁸

Community-based.^1,5

Bridging.^{2,7,18,21,26,32,34}

Team is responsible for a specific patient population (e.g., health condition or at-risk of hospital readmission).^{7,10,12,19,22,26,32,33,34,36}

Flexible team structure so that each patient has the professions they need on their team.^1,16,22

Team co-management of patient care by inpatient geriatric team and usual inpatient team.³⁰

Shared care pathways, protocols and patient educational materials.^1,7,32

Electronic medical record to promote communication, collaboration, care planning and information sharing.^11,19

Team members from more than one setting involved in care planning.¹⁶

Colleagues of same profession from different settings communicate and collaborate on patient care.²²

Joint meetings with hospital and community teams for adult care planning.^5,10

All team members focus on patient goals that are important according to evidence.¹⁶