Introduction
Methods
Study eligibility
Search strategy
Inclusion criteria
Exclusion criteria
Study selection
Data extraction
Analysis
Results
Study characteristics
Author (year) | Country | Study type | Setting | Sample size | Medical condition | Age of children | Intervention | Outcomes |
---|---|---|---|---|---|---|---|---|
Antolick et al. (2020) [24] | USA | Quality improvement project with a pre-post design | Children's hospital | 40 | High risk children (criteria described) | Median 12 years | Post Hospitalization Action Grid (PHAG) and a standardized discharge handoff process. | - Provider and staff perceptions of integrated care - Provider and staff intentions to use the PHAG |
Appachi et al. (2017) [25] | USA | Retrospective medical record review with a pre-post design | Tertiary Care Center for children with medical complexity | 113 | Children with complex medical needs, specifically with aerodigestive disorders (definition described) | Range 0 to 20 years | A multidisciplinary aerodigestive clinic providing a comprehensive and coordinated care program (inpatient and outpatient). | - Number of hospital admissions - Number of hospital days for all admissions per year - Number of admissions in the aerodigestive clinic - Costs |
Baker et al. (2016) [26] | USA | Quality improvement project with a pre-post design | Tertiary care children's hospital | 48 | Children requiring chronic mechanical ventilation via tracheostomy | Neonates | An interdisciplinairy Ventilator Care Program including: education materials, a chronic ventilation road map and instructional videos for caregivers, assessment of discharge readiness, the involvement of an advanced practice nurse and rehabilitation respiratory therapist, and case management. | - Mortality - Number of unplanned hospital readmissions - Hospital length of stay - Number of Emergency Department visits - Costs |
Barreda et al. (2021) [27] | USA | Propensity-matched retrospective cohort design | Children’s Hospital | 566 | Children with medical complexity (criteria described) | Median 5 years (IQR 4-6) | Pediatric Complex Care Program including: comprehensive care planning and care coordination, support by the complex care team for urgent visits, monthly phone calls. | - Number of hospitalisation per year, related to device complications - Number of Emergency Department visits per year, related to device complications |
Braun et al. (2021) [28] | USA | Retrospective matched cohort design | Children’s Hospital | 64 | Children with medical complexity (criteria described) | Mean 5.6 years (SD 7.2) and 5.5 (SD 7.7) | Family Integrated Healthcare Transitions (FLIGHT) team providing care coordination and complex care by a predominantly telemedicine-mediated format. | - Number of hospital admissions per year - Hospital days per year and per admission - Number of subspeciality appointments per year - Missed appointments per year |
Breen et al. (2018) [29] | Australia | Pre-post implementation cohort evaluation | Children’s Hospital Network (two tertiary pediatric hospitals) | 534 | Children with medical complexity (criteria described) | Median 5 years (range 7-19) | Care coordination service: access to a care coordinator, shared-care plan, linkage with local general practitioners, and acces to a 24-hours hotline. | - School absences child - Prevented family travel costs - Number of hospital encounters and admissions (overnight and day-only) - Number of Emergency Department visits - Costs |
Cohen et al. (2010) [30] | Canada | Mixed method descriptive study with a pre-post design | Tertiary care hospital | 28 | Children with medical complexity (criteria described) | Median 1.5 years (range 30 days to 14 years) | Nurse practitioner/pediatrician-run complex care clinic in a tertiary care hospital. | - Quality of life of parents - Parental perceptions of care - Healthcare utilization (inpatient days, Emergency Department visits, visits to hospital and community based practitioners) - Healthcare providers perceptions of care |
Cohen et al. (2012) [31] | Canada | Mixed method, intervention study with a pre-post design | A tertiary care children's hospital and two community hospitals | 81 | Children with medical complexity (criteria described) | Mean 5.8 years (SD 4.7) | Community-based complex care clinics integrated with a tertiary care center. | - Quality of life child - Quality of life of parents - Parental perception of family centered care - Health care utilization (inpatient days, Emergency Department visits, visits to hospital and community based practitioners) - Costs (healthcare system costs and parents reported out of pocket expenses) |
Coller et al. (2018) [32] | USA | Randomized Controlled Trial | Tertiary medical center | 147 | Children with medical complexity | < 18 years | Plans for Action and Care Transition (PACT): written action plans and care transition coaching during the period of hospital discharge. | - Mortality - Number of readmissions - Number of hospitalizations - Costs |
Donnelly et al. (2020) [33] | USA | Retrospective cohort study with a pre-post design | Tertiary children's hospital | 31 | Children with medical complexity (criteria described) | Mean 5.2 years (SD 3.5) | The Advanced Practice Nurse and Care Coordination Assistent model medical care coordination program. | - Quality of life child - Self-efficacy regarding managing child's healthcare needs - Quality of Life of parents - Satisfaction of parents with healthcare |
Duffy and Vessey (2016) [34] | USA | Randomized Controlled Trial | Pediatric teaching hospital | 46 | Children with chronic neurological conditions | 2 to 6 years | Creating Opportunities for Parent Empowerment (COPE) program: an intervention that teaches parents what behaviors they can expect in their child as normal response to illness, and how to help their child to cope with illness experiences. | - Number of behavior problems of the child - Parental belief in their caregiving skills - Anxiety of parents - Depression of parents |
Gay et al. (2016) [35] | USA | Retrospective, matched cohort study | Home Health Care Nursing Care services across 19 states | 10144 | Children with medical complexity | 0 to 18 years | Home Health service: intermittent skilled nursing visits or private duty nursing. | - Number of readmissions - Number of hospitalizations - Number of hospital days - Costs |
Gillen and Morris (2019) [36] | USA | Cohort study with a pre-post design | Urban PICU | 50 | Children with medical complexity | < 18 years | Information and materials to improve the ability of caregivers to care for their children in case of a prolonged home power failure. | - Families' disaster preparedness |
Graham et al. (2018) [37] | USA | Prospective cohort study | Tertiary care center | 346 | Children with chronic respiratory failure | Median 6 years (IQR 1 to 16) | Critical Care, Anesthesia, Perioperative Extension Program (CAPE): an individual tailored and comprehensive longitudinal service and home ventilator program. | - Number of hospitalizations - Number of Emergency Department visits - Costs |
Hogan et al. (2022) [38] | USA | Pre-post design | Pediatric health system with inpatient and outpatient services | 105 | Children with medical complexity (criteria described) | 90% of the children were < 10 years | The Compass Care Program, a consultative complex care program across inpatient and outpatient settings. | - Caregiver satisfaction (communication and access to care) - Number of hospital (re)admissions - Number of hospital readmissions within 7 days. - Number of hospital days - Length of stay per inpatient admission - Number of Emergency Department visits - Cost |
Holland (2015) [39] | USA | Prospective quasi-experimental, non-equivalent comparison group design | Tertriary children's hospital | 300 | Pediatric patients hospitalized in the acute care setting | Mean 8.7 years (SD 5.9) | Early Screen for Discharge Planning Child Version (ESDP-C): a screening tool to identify children with medical complexity that would benefit from early engagement of a discharge planner. | - Time from admission to discharge planner involvement - Number of readmissions - Length of hospital stay |
Howard et al. (2017) [40] | USA | Retrospective cohort study | A Pediatric Hospital and other urban hospitals | 183 | Children with medical complexity, including cerebral palsy | Mean 12.4 years (SD 5.8) and 6.7 (SD 4.4) | Care beyond The Bedside Model: increasing the preparedness and comfort level of children and their caregivers to manage ongoing health care needs independently. | - Number of readmissions - Number of inpatient days - Number of Emergency Department visits - Costs |
Knight et al. (2013) [41] | USA | Observational survey-based study | Quarternary, academic pediatric hospital | 117 | High risk children (criteria described) | 0 to 18 years | Cardiopulmonary resuscitation (CPR) discharge training. | - Parental knowledge of the core skills of CPR - Parents comfort levels in performing CPR - Frequency of video review and practising core skills after discharge by parents - Disemmination of the kit to other family and friends - Nurses' impression of the program and suggestions for improvement |
Lerret et al. (2020) [42] | USA | Quality improvement project with a pre-post two group design | Academic medical center | 395 | Children with and without a chronic condition | 2 to 21 years | The engaging Parents in Education for Discharge (ePed): a tool that explores parents experiences with discharge teaching and care coordination. | - Quality of discharge teaching - Quality of care coordination - Number of readmissions |
Liu et al. (2018) [43] | USA | Cohort study with propensity score weighting | Tertiary Women and Infant hospital | 686 | High risk neonates (criteria are described) | 0 to 1 year | Transition to Home Plus (THP) program: enhanced support services before and after discharge. | - Number of unplanned readmissions - Number of Emergency Department visits - Costs |
Ming et al. (2022) [44] | USA | Non-randomized pilot study | Tertiary children’s hospital | 48 | Children with medical complexity (criteria described) | Mean 8.5 years (SD 5.6) and 10.1 years (SD 5.1) | Post-hospitalization telemedicine video visits during hospital-to-home transitions. | - Acceptability of the intervention (parents) - Saved travel costs - Self-efficacy - Number of hospital admissions - Length of hospital stay - Length of ICU stay - Number of Emergency Department visits |
Moreno and Peck (2020) [45] | USA | Quality improvement project with a pre-post intervention design | Freestanding pediatric hospital | 2 | Children with a newly placed tracheostomy | Not reported | A hospital-based discharge protocol and telehealth follow-up care. | - Caregiver knowledge, competence, self-efficacy and satisfaction - Number of hospitalizations - Number of Emergency Room visits - Number of tracheostomy-associated complications |
Mosquera et al. (2021a) [46] | USA | Randomized Quality Improvement Trial | High-Risk Children’s Clinic | 422 | Children with medical complexity (criteria described) | Mean 6.2 years (SD 5.4) and 5.7 years (SD 4.5) | Care coordination with telemedicine. | - Mortality - Serious illness - Hospital (re)admissions - Number of PICU admission - Number of hospital days - Hospital length of stay - PICU length of stay - Number of Emergency Department visits - Number of office visits - Well-child checks - Costs |
Mosquera et al. (2021b) [47] | USA | Randomized Quality Improvement Trial | High-Risk Children’s Clinic | 342 | Children with medical complexity (criteria described) | Mean 5.8 years (SD 4.2) and 6.3 years (SD 4.7) | A hospital consultation service for CMC from their outpatient comprehensive care clinicians | - Mortality - Serious illness - Parental satisfaction healthcare - Hospital (re)admissions - Number of PICU admission - Number of hospital days - Hospital length of stay - PICU length of stay - Number of Emergency Department visits - Number of telephone conversations after discharge - Costs |
Moyer et al. (2014) [48] | USA | Concurrent cohort study | Children's hospital | 229 | Preterm children (criteria described) | Preterm infants | Care Transitions Intervention: a care transition coach to assist families, and an enhanced personal health record to improve the quality of information available to parents and community professionals. | - Mortality - Number of sick visits - Number of unplanned readmissions - Number of Emergency Department visits - Caregiver perception of perceived quality of transitional care - Non-compliance with follow-up appointments |
Nguyen et al. (2018) [50] | USA | Prospective cohort study | Freestanding pediatric hospital | 311 | Children with medical complexity (criteria described) | Range 0 to 17 years | Pharmacy discharge services additional to an existing nurse-led discharge service. | - Number and type of pharmacist interventions during discharge and telephone encounters - Costs |
Nkoy et al. (2021) [49] | USA | Randomized controlled trial | Tertiary children’s hospital | 50 | Children with medical complexity (criteria described) | Mean 9.65 years (95% CI 7.40 to 11.91) and 7.29 years (95% CI 4.90 to 9.69) | A home monitoring application (mobile app) additional to the usual care coordination program. | - Health deteriorations - Quality of life child - Satisfaction with healthcare - Hospital admissions - Hospital days - Number of Emergency Department visits |
Noritz et al. (2017) [51] | USA | Quality improvement project with a pre-post design | Freestanding quaternary children's hospital and the affiliated accountable care organizations | 1070 | Children with medical complexity (criteria described) | Range 1 to 18 years | Program with 3 interventions: standardizing percutaneous feeding tube management, improving family education, and care coordination. | - Number of children with a weight between 5th and 95th percentile on standard growth curve - Length of stay - Costs |
Osorio et al. (2021) [52] | USA | Factorial design of a natural experiment | Four children’s hospitals | 7725 | Multiple or complex chronic conditions, including technology-supported patients | Median 1.9, 2.4, 0.7 and 3.6 years | Pediatric Care Transition (PACT) bundel: (a) a transition readiness checklist, (b) predischarge teach-back education, (c) written handoff to primary care professional, and (d) postdischarge phone call. | - Hospital readmission rate |
Parker et al. (2020) [53] | USA | Cohort study with a comparison group | University-affiliated tertiary care children's hospital | 126 | Children with chronic respiratory insufficiency requiring technological support | Median 7 years (IQR 3 to 12) | The Center for Children with Complex and Chronic Conditions (C5) program: inpatient and outpatient care coordination. | - Number of readmissions - Number of Emergency Department visits - Costs |
Patel et al. (2017) [54] | USA | Prospective observational cohort study | Regional NICU | 241 | High risk neonates (criteria described) | born < 32 weeks gestational age | BRIDGE: home visits by pediatric nurse practitioners. | - Number of adverse events: homecare and healthcare utilization errors, such as errors with medication, feeding and equiment use, - Non-compliance with follow-up appointments |
Petitgout (2018) [55] | USA | Retrospective cohort study with a pre-post design | Tertiary children's hospital | 158 | Children with a tracheostomy | ≤ 21 years | Hospital-based care coordination program: interdisciplinary family centered care, continuity of care, psychosocial support, assessment of recources and services, communication, avoidance of duplication of services and improving overall health of the child. | - Number of unplanned hospital readmissions - Length of stay - Costs |
Postier et al. (2014) [56] | USA | Retrospective cohort study with a pre-post design | Pediatric hospital | 425 | Children with life-limiting and life-threatening illnesses | 1 to 21 years | Pediatric Palliative Care program (PCC): a home-based pediatric hospice program. | - Number of hospital admissions - Length of stay - Costs |
Prickett et al. (2019) [57] | USA | Evaluation study | Pediatric hospital | 39 | Children with a newly placed tracheostomy | Not reported | Tracheostomy simulation-based education program for caregivers: classroom learning, one-on-one teaching, bedside teaching and caregivers skills demonstrations. | - Parental self confidence with tracheostomy emergency management - Utility of tracheostomy emergency management |
Roundy et al. (2016) [58] | USA | Cohort study with historical controls | Tertiary children's hospital. | 120 | Children with epilepsy | 0 to 18 years | Seizure Action Plan (SAP): information that might be forgotten and difficult to remember, and that would be helpful in a situation of breakthrough seizures or for determining timing of follow-up. | - Number of readmissions - Length of stay - Number of Emergency Department visits - Number of neurology follow-up clinic visits - Number of telephone calls to pediatric neurology offices |
Sarik et al. (2018) [59] | USA | Retrospective review | Pediatric acute care setting in a Magnet designated hospital | 398 | Children with medical complexity (criteria described) | 0 to 20 years | Patient navigation program: assessment of the readiness for discharge, planning of the sequential order of appointments, implementing stategies to help families succesfully care for their child. | - Number of readmissions - Rate of no-show at scheduled follow-up appointments |
Sigalet et al. (2014) [60] | Canada | Randomized Controlled pilot Trial | Children's hospital | 61 | Children with acute seizure disorders | < 18 years | Simulation-based seizure management teachingprogram. | - Caregivers self-efficacy - Caregivers performance assessed by the trainer |
Statile et al. (2016) [61] | USA | Quality improvement project | Freestanding pediatric hospital | 227 | Children with neurologic medical complexity (categories described) | Median 5.3 years (IQR 2.2 to 15.6) | Quality improvement interventions, such as defining medical discharge goals, admission order sets, care coordination rounds, needs assessment tool, and medication pathway. | - Number of children discharged within 2 hours of meeting medical discharge goals - Number of readmissions - Length of hospital stay |
Thrasher et al (2018) [62] | USA | Quality improvement project | University-affiliated tertiary care children's hospital and regional referral centers | 87 | Children with a tracheostomy requiring long-term mechanical ventilation | Median 11.5 months (range 2 to 410) | Simulation training incorporated into a multimodal discharge preparedness training with instructional videos, printed handouts, scenario training, and video based debriefing. | - Number of readmissions |
Tiozzo et al. (2022) [63] | Italy | Prospective cohort study | Pediatric hospital | 310 | Children with chronic diseases and complex therapeutic plans | 0 to 18 years | A Medication Safety at Home cell-phone app. | - Number and features of out-of-hospital medication errors |
Tofil (2013) | USA | Quality improvement project | Department of pediatric pulmonology | 7 | Children with a trachestomy and home ventilation | Range 15 months to 15 years | Home ventilator program with simulation training. | - Parents perceived preparedness and confidence to provide care to their child |
Tolomeo et al (2017) [65] | USA | Quality improvement project | Pediatric Respiratory Care Unit | 30 | Children with a trachestomy | < 1 year | Standardizing the care and skills proficiency training for parents of infants with trachestomy tubes: welcome binder and educational material. | - Number of developmental interventions for infants with tracheostomy tubes - Length of stay |
Vohr et al. (2017) [66] | USA | Prospective cohort study | NICU (level 3-4) | 804 | High risk / very low birth weight preterm infants | Born ≤ 37 weeks gestational age | Comprehensive transition home services: predischarged interventions (e.g. education, support to assess community resources) and postdischarge interventions (e.g. contact with primary care provider). | - Number of rehospitalization |
Vohr et al. (2018) [67] | USA | Prospective cohort study | NICU (level 3-4) | 804 | High risk / very low birth weight preterm infants | Early, moderate and late preterm infants. | NICU transition support services: predischarged interventions (e.g. education, support to assess community resources) and postdischarge interventions (e.g. contact with primary care provider and visits to follow-up clinic). | - Number of Emergency Department visits |
Wells et al. (2017) [68] | USA | Prospective cohort study | Children's hospital | 38 | Children with medical complexity (criteria described) | Median 6 years (IQR 2 to 18) | Postdischarge home visits. | - Unresolved health issues - Parental satisfaction with home visits - Postdischarge problems (number and type) |
Whalen et al. (2020) [69] | USA | Descriptive quantitative design | Children's hospital | 8 | Childeren with a tracheostomy, some requiring mechanical ventilation | ≤ 18 years | Parental Airway Assessment with Simulation program. | - Parent tracheostomy skills |
Willard et al. (2018) [70] | USA | Prospective cohort study | NICU (quaternary level 4) | 93 | Children with medical surgical complexity | Infants | Postdischarge telemedicine visits, as additional to the existing discharge process (education and home care coordination). | - Caregivers knowledge and practice gaps uncovered - Caregiver perceived satisfaction |
Yilmaz and Ozsoy (2010) [71] | Turkey | A quasi-experimental study | Pediatric oncology unit | 49 | Children with newly diagnosed cancer | Mean 8.7 years (SD 5.9) and 10.7 years (SD 4.2) | A discharge planning program, including discharge planning, discharge teaching, home visits and postdischarge telephone consultation. | - Physical care needs of the children (number and characteristics) - Number of readmissions Number of clinic visits |
Yuen et al. (2021) [72] | USA | Pilot study with a pre-post design | Children’s hospital within a tertiary academic medical center | 25 | Children with tracheostomy | < 21 years | Simulation-based Discharge Program | - Caregivers’ comfort and confidence to perform care at home - Caregivers’ skills to provide care |
Zanello et al. (2017) [73] | Italy | Prospective cohort study | Hospitals participating in the Special Needs Kids Research Project | 61 | Children with medical complexity (criteria described) | Mean 5.8 months (SD 11.8) | Family Pediatrician: care coordination by pediatricians in primary care. | - Patient's needs requiring care coordination - Activities by the Family Pediatricians (number and type) - Prevented healthcare utilization |
Outcomes
Outcome | Data sources | References |
---|---|---|
Domain 1: mortality and survival (1 outcome) | ||
Mortality (five studies, 10%) | Data from institutional databases or electronic medical records | |
Domain 2: physical health (1 outcome) | ||
Disease management, in terms of e.g. serious illness, health deteriorations, or physical care needs (seven studies, 14%) | Electronic medical records, e.g. growth curve, development assessments, unresolved health issues Mobile app for monitoring child’s vital signs and symptom Children's Physical Care Needs (CPCN) measurement tool | |
Domain 3: life impact (13 outcomes) | ||
Outcomes reflecting the impact on the life of the child | ||
Quality of Life (three studies, 6%) | Measurement tools: Child Health-Related Quality of Life (PedsQL) Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) A self-structured questionnaire based on existing validated surveys: Medical Home Family Index and the Client Perception of Coordination Questionnaire (CPCQ) Adapted survey based on Parent Perceptions of quality of life and healthcare satisfaction for CMC | |
Behavioral problems (one study, 2%) | Measurement tool: Behavior Assessment System for Children - Parent Report Scale (BASC2-PRS) | Duffy and Vessey [34] |
School absences among children agedover 5 years (one study, 2%) | Data collected by care coordinators on prevented hospital visits | Breen et al. [29] |
Outcomes reflecting the impact on the life of the parents | ||
Self-efficacy (nine studies, 18%) | Measurement tools: Parental Beliefs Scale A self-structured questionnaire based on existing validated surveys: Medical Home Family Index and the Client Perception of Coordination Questionnaire (CPCQ) KidSIM-ASPIRE Parent Seizure Self-efficacy Questionnaire Care Transitions Measure Survey (CTMS) CPR Skill Competence Checklist 10-point rating scale Caregiving self-efficacy (CSE) Family self-management (FSM) self-constructed survey/assessment tool | |
The competency of parents to provide care for their child (eight studies, 16%) | Measurement tools: Parents Airway Assessment with Simulation skill checklists Caregiver Knowledge Checklist (CKC) the KidSIM-ASPIRE Emergent Seizure Management Checklist CPR Skill Competence Checklist self-constructed survey / assessment tool | |
Satisfaction with hospital-to-home transitional care (eight studies, 16%) | Measurement tools: Self-structured questionnaire based on existing validated surveys: Medical Home Family Index and the Client Perception of Coordination Questionnaire (CPCQ) Telehealth Satisfaction Survey (TSS) Care Transition Measure (CTM) Care Transition Measure neo (CTM Neo) delivery subscale of the Quality of Discharge Teaching Scale (QDTS-D) Self-constructed survey / assessment tool Telehealth Usability Questionnaire Survey adapted from: (a) the Consumer Assessment of Healthcare Providers and Systems Patient-Centered Medical Home survey and b) Medicare Coordinated Care Demonstration survey. | |
Compliance, in term of missed appointments to an outpatient department/clinic/subspecialist (four studies, 8%) | Data from institutional databases or electronic medical records | |
Quality of Life (three studies, 6%) | Measurement tools: Parental Health-Related Quality of Life (SF-36) A self-structured questionnaire based on existing validated surveys: Medical Home Family Index and the Client Perception of Coordination Questionnaire (CPCQ) | |
Satisfaction with healthcare in general (three studies, 6%) | Measurement tool: Larsen's Client Satisfaction Questionnaire (LCSQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Adapted survey based on the Client Satisfaction Questionnaire | |
Out-of-pocket expenses (three study, 6%) | Measurement tool: Health and Social Service Utilization Questionnaire for expenditures: parents reported out of pocket expenses Travel costs savings estimated from prevented hospital visits | |
Satisfaction with family centered care (two studies, 4%) | Measurement tool: Measures of Processes of Care (MPOC) | |
Anxiety (one study, 2%) | Measurement tool: State-Trait Anxiety Inventory (STAI-Y) | Duffy and Vessey [34] |
Depression (one study, 2%) | Measurement tool: Beck Depression Inventory II (BDI-11) | Duffy and Vessey [34] |
Domain 4: Resource use (8 outcomes) | ||
Hospital (re)admissions (30 studies, 60%) | Measurement tool: Adapted Care Coordination Measurement Tool (CCMT) Data from institutional databases or electronic medical records | Appachi et al. [25], Baker et al. [26], Barreda et al. [27], Braun et al. [28], Breen et al. [29], Coller et al. [32], Gay et al. [35], Graham et al. [37], Hogan et al. [38], Holland et al. [39], Howard et al. [40], Lerret et al. [42], Liu et al. [43], Ming et al. [44], Moreno and Peck [45], Mosquera et al. [46, 47], Moyer et al. [48], Nkoy et al. [49], Osorio et al. [52], Parker et al. [53], Petitgout [55], Postier et al. [56], Roundy et al. [58], Sarik et al. [59], Statile et al. [61], Thrasher et al. [62], Vohr et al. [70],Yilmaz et al. [71], Zanello et al. [73] |
Length of hospital stay (19 studies, 38%) | Data from institutional databases or electronic medical records | Appachi et al. [25], Baker et al. [26], Braun et al. [28], Cohen et al. [30], Cohen et al. [31], Gay et al. [35], Hogan et al. [38], Holland et al. [39], Howard et al. [40], Ming et al. [44], Mosquera et al. [46, 47], Nkoy et al. [49], Noritz et al. [51], Petitgout [55], Postier et al. [56], Roundy et al. [58], Statile et al. [61], Tolomeo et al. [65] |
Number of visits Emergency Department (19 studies, 38%) | Data from institutional databases or electronic medical records | Baker et al. [26], Barreda et al. [27], Breen et al. [29], Cohen et al. [30], Cohen et al. [31], Graham et al. [37], Hogan et al. [38], Howard et al. [40], Liu et al. [43], Ming et al. [44], Moreno and Peck [45], Mosquera et al. [46, 47], Moyer et al. [48], Nkoy et al. [49], Parker et al. [53], Roundy et al. [58], Vohr et al. [66], Zanello et al. [73] |
Costs (17 studies, 34%) | Data from institutional databases or insurance databases | |
Number of contacts to an outpatient department/clinic/ subspecialist (nine studies, 18%) | Data from institutional databases or electronic medical records | |
Number of primary care consultations or visits to a community based clinic (two studies, 4%) | Data from institutional databases or electronic medical records | |
Services carried out by a pharmacist (one study, 2%) | Electronic medical records and a self-constructed tool | Nguyen et al. [50] |
Number of activities performed by primary care professionals, e.g. laboratory tests, examinations, coordination services (one study, 2%) | Measurement tool: Special Needs Kids-Family Pediatrician (SpeNK-FP) | Zanello et al. [73] |
Domain 5: adverse events (1 outcome) | ||
Identification, number and features of out-of-hospital medication and equipment errors (four studies, 8%) | Data collected by care coordinators on adverse events at home during home visits. Home cell-phone app | |
Other: Staff perceptions (1 outcome) | ||
Staff perception about the transitional care, in term of feasibility, usability and satisfaction (three studies, 6%) | Provider and Staff Perceptions of Integrated Care Survey Self-constructed survey |