European Geriatric Medicine https://doi.org/10.1007/s41999-020-00365-4 REVIEW The effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review Duygu Sezgin1 · Rónán O’Caoimh2,3 · Aaron Liew3,4 · Mark R. O’Donovan5 · Maddelena Illario6 · Mohamed A. Salem7 · Siobhán Kennelly8 · Ana María Carriazo9 · Luz Lopez‑Samaniego10 · Cristina Arnal Carda11 · Rafael Rodriguez‑Acuña10 · Marco Inzitari11 · Teija Hammar12 · Anne Hendry13,14 on behalf of all EU ADVANTAGE Joint Action Work Package 7 partners Received: 21 February 2020 / Accepted: 11 July 2020 © European Geriatric Medicine Society 2020 Key summary points Aim This scoping review examined the effectiveness of intermediate care including transitional care interventions for middle- aged and older adults on function, healthcare utilisation, and costs. Findings While some studies report positive outcomes on hospital utilisation, the evidence is limited for their effectiveness on emergency department attendances, institutionalisation, function, and cost-effectiveness. Message Intermediate care including transitional care interventions were associated with reduced hospital stay but this finding was not universal. Abstract Background and aim Intermediate care describes services, including transitional care, that support the needs of middle-aged and older adults during care transitions and between different settings. This scoping review aimed to examine the effective- ness of intermediate care including transitional care interventions for middle-aged and older adults on function, healthcare utilisation, and costs. Design A scoping review of the literature was conducted including studies published between 2002 and 2019 with a tran- sitional care and/or intermediate care intervention for adults aged ≥ 50. Searches were performed in CINAHL, Cochrane Electronic supplementary material The online version of this article (https​://doi.org/10.1007/s4199​9-020-00365​-4) contains supplementary material, which is available to authorized users. 8 * Duygu Sezgin Royal College of Surgeons in Ireland Connolly Hospital, duygu.sezgin@nuigalway.ie Dublin and Health Service Executive, Dublin, Ireland 9 1 Regional Ministry of Health and Families of Andalusia, School of Nursing and Midwifery, National University Seville, Spain of Ireland Galway, Galway, Ireland 10 2 Andalusian Public Foundation Progress and Health, Seville, Department of Geriatric Medicine, Mercy University Spain Hospital Cork, Cork, Ireland 11 3 REFiT Barcelona Research Group, Parc Sanitari Pere Virgili Clinical Sciences Institute, National University of Ireland and Vall D’Hebron Institute of Research (VHIR), Universitat Galway, Galway, Ireland Autònoma de Barcelona, Barcelona, Spain 4 Department of Endocrinology, Portiuncula University 12 Finnish Institute for Health and Welfare (THL), Helsinki, Hospital, Ballinasloe, Co Galway, Ireland Finland 5 University College Cork, Cork, Ireland 13 NHS Lanarkshire, Bothwell, UK 6 Campania Region Health Innovation Unit, and Federico II 14 School of Health and Life Sciences, University of the West Department of Public Health, Naples, Italy of Scotland, Hamilton, UK 7 St Vincent De Paul LTC Facility, Luqa, Malta 13 Vol.:(0123456789) European Geriatric Medicine Library, EMBASE, Open Grey and PubMed databases. Qualitative and quantitative approaches were employed for data synthesis. Results In all, 133 studies were included. Interventions were grouped under four models of care: (a) Hospital-based transi- tional care (n = 8), (b) Transitional care delivered at discharge and up to 30 days after discharge (n = 70), (c) Intermediate care at home (n = 41), and (d) Intermediate care delivered in a community hospital, care home or post-acute facility (n = 14). While these models were associated with a reduced hospital stay, this was not universal. Intermediate including transitional care services combined with telephone follow-up and coaching support were reported to reduce short and long-term hospital re- admissions. Evidence for improved ADL function was strongest for intermediate care delivered by an interdisciplinary team with rehabilitation at home. Study design and types of interventions were markedly heterogenous, limiting comparability. Conclusions Although many studies report that intermediate care including transitional care models reduce hospital utilisa- tion, results were mixed. There is limited evidence for the effectiveness of these services on function, institutionalisation, emergency department attendances, or on cost-effectiveness. Keywords Intermediate care · Transitional care · Frailty · Older adults · Models of care Introduction and cost-effectiveness for adults, particularly older, frail and multi-morbid adults [17]. Therefore, this scoping review Intermediate care including transitional care services are seeks to identify and analyse a broad range of literature pub- models of care that support the integration and continuity lished in relation to the effectiveness of intermediate care of care as well as prevention of avoidable admissions to hos- including transitional care for middle-aged and older adults pital [1–3]. They have a particular importance in preventing and to understand the benefits of these interventions, with the onset and progression of frailty and functional decline a specific focus on health-related outcomes including func- in adults, particularly older adults [4, 5] since they provide tion (activities of daily living), healthcare use and associated comprehensive geriatric assessment, enablement and reha- costs. bilitation aimed at optimising independence and recovery [4–6]. These services are time limited [7] as they are mainly employed at times of a deterioration in health or at times of transition such as when moving from one’s home to hospital, Methods assisted living or long-term care [8, 9]. These models operate as part of the continuum of care. Scoping reviews are conducted as a preliminary investi- They help manage preventable complications associated gation to assess the potential size and scope of available with hospitalisation and enable older adults to maintain or research literature on a topic [18]. They are useful in sum- recover their functional ability following an illness, injury marising evidence to show the breadth and depth of a given or hospital admission [6, 10]. A recent Delphi study exam- field [19]. This scoping review was conducted to incorporate ining these models emphasised that intermediate care is evidence from the existing literature across a broad range of a broad range of time-limited services, ranging from cri- study designs regarding the effectiveness of intermediate sis response to support over weeks to months that aims and transitional care interventions for middle-aged and older to ensure continuity, improve quality of care and promote adults. The methodological framework recommended by recovery, particular at transitions between different levels of Arksey and O’Malley [20] for conducting a scoping review care and settings [11],transitional care interventions may be was used and the following steps were taken: 1-identifica- delivered as a subset of intermediate care [11, 12]. Although tion of the research question, 2-identifying relevant studies, transitional and intermediate care services may be limited to 3-study selection, 4-charting the data, 5-collating, summa- several weeks [13, 14], they are more comprehensive than rising and reporting the results. discharge planning activities or chronic care management [11]. In addition, both services provide care closer to home, support early discharge and reduce readmission to acute care Protocol and registration [15, 16]. Despite the recent growth in their use as a bridge to The Preferred Reporting Items for Systematic Review and care transitions, there is limited data on the impact of these Meta-Analyses (PRISMA) extension for scoping reviews relatively new models of care on activities of daily living (PRISMA-ScR) guidelines were used for reporting purposes (ADL) function-related outcomes, healthcare utilisation 13 European Geriatric Medicine [21]. The review protocol was registered on PROSPERO articles and grey literature that did not meet these criteria (CRD42019122982). were excluded. Titles and/or abstracts (where available) of the located Objectives records were independently screened by three pairs of reviewers (DS-AH, AMC-LLS, RRA-CAC) considering the The primary objective of this scoping review was to iden- inclusion and exclusion criteria. Disagreements were dis- tify the effectiveness of intermediate care including transi- cussed by the pairs of reviewers and any persisting conflict tional care interventions for middle-aged and older adults was resolved by a third independent reviewer. Data extrac- (aged ≥ 50) in the existing literature. tion was performed by five reviewers (DS, AH, MOD, MS, The following research questions were explored: LLS) for the full-text records. • What are the models of intermediate and transitional care Data charting process and data items provided in different care settings? • Is there evidence for their effectiveness in improving Data extraction was carried out using a single standard function, and reducing hospital length of stay, Emer- template. This template had fifteen sections including: (1) gency Department (ED) admissions, institutionalisa- Author names, year, title, and country; (2) Evidence type; tion, and health and social care costs for middle-aged (3) Aim of study; (4) Definitions provided for transitional and older adults? or intermediate care; (5) Intervention details; (6) Technol- • Are intermediate and transitional care interventions ogy usage; (7) Population characteristics (such as mean age effective for other outcomes such as satisfaction with care and sample size); (8) Health condition/problem; (9) Con- transitions, quality of life, and adherence to treatment text/setting that the recruitment took place; (10) Structure/ plans? governance of intervention; (11) Outcomes reported (func- tion, ED visits, hospital stay, institutionalisation, other); Information sources (12) Resource implications (such as cost and staffing); (13) Transferable lessons for policy and practice; (14) Barriers/ The search was conducted in four databases, CINAHL, limitations reported; and (15) Additional recommendations/ Cochrane Library, EMBASE, and PubMed, using the search comments. string: ((“intermediate care” OR “transitional care”) AND (frailty OR frail OR “older person*” OR “older adult*” OR Synthesis of the results “hospital at home” OR “reablement” OR “independ*” OR “readmission” OR “prolonged stay” OR “community hos- Qualitative and quantitative analyses of the included studies pital”)). OpenGrey was also searched with the terms “inter- were performed. The included studies were read in detail and mediate care” or “transitional care” for reports published were grouped and classified according to their type and set- within the same period. ting. The measures captured by the data extraction template guided the data synthesis process (supplementary file). Clas- Eligibility criteria sification and synthesis of studies were discussed within the team and decisions were made with consensus. A core team Studies that investigated the effectiveness of intermediate of reviewers (DS, AH, MOD, MS) had regular email cor- or transitional care interventions for adults aged 50 and respondence and virtual meetings to classify and synthesise over were included from peer-reviewed literature published data from included studies. between 01/01/2002 and 05/02/2019 in English, French, Ital- ian or Spanish. Any care setting was considered. Results Selection of sources of evidence The initial search yielded 1891 records. Cross-referenc- Articles and grey literature that met the following criteria ing of a systematic review and narrative review articles were included: (a) report an intervention for intermediate or resulted in 79 additional articles. The search for grey lit- transitional care; (b) had a sample of adults aged 50 and over erature added a further 14 reports, resulting in a total of or mean age of the sample was at least 50; (c) conducted in 1984 articles for screening. Further details of the screen- any health care setting; (d) published in English, French, ing process are outlined in Fig. 1 (PRISMA-ScR flow Italian or Spanish; (e) published between 01 January 2002 diagram). In total, 133 studies measuring the effective- and 05 February 2019; and (f) had full text available. Any ness of transitional and/or intermediate care interven- tions in middle-aged and older adults (aged ≥ 50) were 13 European Geriatric Medicine Fig. 1  PRISMA-ScR flow diagram for the scoping review on the effectiveness of intermediate and transitional care interventions identified. Details on the characteristics and outcomes ranged between 50–86.2 years. Overall, the mean age of these studies are summarised in the supplementary was 73.6 ± 9.48 years. Twenty-nine interventions were file. In summary, the total number of participants in the delivered to high-risk patient populations, e.g. those with included studies were 703,523, with the sample sizes rang- advanced age, high risk of readmission, multimorbidity, ing between 21 and 552,414 (available for 130 studies). though there was no standard description for high-risk. Most studies were from the USA (n = 75). Eighty stud- Only three interventions were designed primarily for frail ies reported the mean age of their participants, which older adults. Interventions were heterogeneous, and most Table 1  Types of evidence with a summary of interventions on the effectiveness of intermediate and transitional care interventions Type of evidence (study Total Transitional care Transitional care delivered at Intermediate care Intermediate care delivered design) delivered only in discharge and up to 30 days delivered at home in a community hospital, care hospital after discharge home or post-acute facility Randomised controlled trial 47 1 25 16 5 Pre-post intervention study 18 1 9 6 2 Quasi experimental 16 3 8 3 2 Retrospective cohort 15 1 13 1 0 Cohort 9 0 2 5 2 Prospective observational 7 1 2 4 0 study Retrospective analysis 7 0 0 4 3 Pilot 6 0 6 0 0 Other 8 1 5 2 0 Total 133 8 70 41 14 13 European Geriatric Medicine Table 2  Number of studies reporting important healthcare outcomes according to the category of interventions examined (alone or in combina- tion) Intervention category Key outcomes Function ED visits Hospital Institu- Costs or ADL readmission tional care Transitional care delivered only in hospital (n = 8) 1 2 4 1 2 Transitional care delivered at discharge and up to 30 days after discharge (n = 70) 4 9 48 0 12 Intermediate care delivered at home (n = 41) 9 4 26 2 6 Intermediate care delivered in a community hospital, care home or post-acute facil- 6 0 11 3 2 ity (n = 14) Pre-discharge stage Post-discharge stage Outcomes Transional care Intervenons delivered at discharge and up to 30 days aer discharge Intermediate care in a Intermediate care at home Transional care intervenons community hospital, care a) Service provider and approach a) Professionals delivering the delivered only in hospital home or post-acute facility • Outreach by hospital professional(s) intervenons • Co-ordinaon and hospital- • Community based or in-reach models • Needs assessment and • Interdisciplinary support Improved funcon or ADL based educaon for paents • Transional care clinics Reduced hospital readmissions rehabilitaon with/without rehabilitaon and/or caregivers • Rapid transfer from acute care • Single profession led Delayed transfers to instuonal care • Implemented discharge planning b) Focus of the intervenons (muldisciplinary) • Educaon and training for intervenons Reduced costs • Telephone follow-up exisng staff b) Approach to care • Paent and caregiver educaon or coaching • Crisis response or hospital • Decision support systems admission avoidance • Home visits for follow-up Fig. 2  Summary of interventions and their outcomes were complex, consisting of a mixture of multiple ele- reductions in readmissions were reported for a combination of ments delivered in hospital and/or in the community set- patient education and discharge planning by nurses or social tings. In total, sixty-five studies were delivered by inter- workers, reduced rates of admission to long-term care was disciplinary teams. As illustrated in Tables 1, 2 and Fig. 2, observed [25]. the interventions were grouped under four main categories based on the type of evidence, location, timing of care and Transitional care interventions delivered healthcare outcomes: at discharge and up to 30 days after discharge Transitional care interventions delivered Many studies (53%) reported on transitional care deliv- only in the hospital ered in hospital and for up to 30 days after discharge, with fifty-five conducted in the USA or Canada, six in Only eight studies examined transitional care interventions Hong Kong, six in Europe, and three in Australia. Most delivered exclusively in the hospital. These focused on co- comprised a complex bundle of interventions in hospital ordination and hospital-based education for patients and/or and in the community delivered by a nurse, pharmacist or caregivers and implemented discharge planning, of which social worker; and 22 (30%) were interdisciplinary. Since the majority were a nurse or social worker-led interventions. these complex multi-component interventions were very Reduced readmission was observed for coaching delivered by heterogenous, the studies were further classified accord- social workers [22], as well as some transitional care interven- ing to their provider, approach and specific focus, to better tions delivered by hospitalists or nurses [23, 24]. While no 13 European Geriatric Medicine describe the potential benefits and value. Some studies in the USA involved immediate identification and telephone were included under more than one category. services for recently discharged patients (mean age 58) [33], reduced readmissions at 30 and 180 days. Pre- and post- Service provider and approach discharge assessments for care needs, medication reconcilia- tion, support for self-care delivered by a primary care-based Outreach by hospital professional(s) (n = 51) The majority nurse care coordinator reduced post-discharge costs among of studies implemented and evaluated combined interven- 638 Medicare fee-for-service beneficiaries discharged from tions including education, assessment, follow-up, medica- hospital and the primary care provider in the USA [34]. tion management and other interventions but were markedly heterogenous. Outreach by a hospital-based professional, Transitional care clinics (n = 7) Transitional care clinics were often a nurse, was described in most of the transitional care assessed in seven studies and were often combined with tel- models. Key positive outcomes of these interventions were ephone and/or nurse follow up. A retrospective study [35] on hospital readmissions (n = 34), ED visits (n = 8), and reported reduced rehospitalisation for patients who com- costs (n = 6). Only one study reported positive outcomes pleted a scheduled transition clinic appointment compared related to function [26], none were reported for institutional with those who neither attended the transition clinic nor care. For example, a telephone-based nurse-led outreach their primary care physician. Similarly, a reduction in re- model, aiming at empowering older adults and caregivers in hospitalisation, as well as potential Medicare savings were medication management and encouraging them to contact observed by Baldwin et al. [36] for patients attending a mul- healthcare providers when needed, reduced 30-day re-hos- tidisciplinary discharge clinic in the USA. pitalisation rates from 34 to 23% [27] and led to estimated net healthcare cost savings of $663 per person [28]. Focus of the interventions One-third of the outreach interventions associated with reduced hospital stay were delivered via interdisciplinary Telephone follow‑up (n = 69) Forty-eight studies illustrated teams. An example of an outreach transitional care pro- a variety of telephone support interventions ranging from gramme is The Bridge Care Coordinator model, which one or two ‘light touch’ prompts in the first few days after involves discussion of the cases within a multidisciplinary discharge to more frequent calls for up to 30 days after dis- hospital team, review of inpatient medical records by a charge. The effectiveness of telephone support was mixed. social worker, and home follow-up visits. The Bridge Care For example, a RCT including 1950 participants (974 inter- model also reported reductions in 30-day re-hospitalisation vention, 975 control) aged ≥ 65 (mean age 74) [37] reported by 20% [29], with average hospital costs reduced by $14,150 insignificant results for a single scripted telephone call from per person per episode of care [30]. a trained nurse following discharge from the ED for 30-day rehospitalisation or death. However, a pre-discharge holis- Community based or in‑reach models (n = 24) Community- tic assessment and telephone support by a social worker based providers were involved in less than half of the post- at 30 days for medical and surgical inpatients aged ≥ 65 discharge transitional care interventions. These models were improved adherence with follow-up appointments in pri- mostly associated with reduced hospital stay [31], fewer mary care settings [38]. rehospitalisations (reductions ranged between 2.2–43%) Twenty-one studies (30%) conducted home visits along- (n = 17), and lower costs (ranged between $192–1964 per side telephone follow-up as part of their intervention. There patient, where applicable) (n = 7). Few illustrated positive was mixed evidence for a reduction in re-hospitalisation for outcomes on ED visits (n = 3) and ADL function (n = 3). interventions delivered by different healthcare professionals. None reported outcomes on institutional care. Almost all the For example, a pilot study [39] investigating home visits by models (n = 16) that were associated with reduced hospital social workers in 620 high-risk patients in the USA reported stay consisted of combined interventions, six of which were lower ED visits and rehospitalisation at 30 days post-dis- delivered via interdisciplinary teams. All interventions that charge. Similarly, home visits on day five post-discharge by reported reduced costs implemented patient or carer educa- a pharmacist [40] reduced 90-day unplanned rehospitalisa- tion and used telephone support. tion and improved compliance in those aged ≥ 60 (median A large retrospective study of The Preventable Admis- age 74) in Australia. However, in another study, home vis- sions Care Team, an in-reach model involving a social its by pharmacists at two and eight weeks post-discharge worker-led in-hospital holistic assessment and personalised were linked to increased hospitalisation in 872 patients with care planning, followed by home-based post-discharge care emergency admission aged ≥ 80 (mean age 85) in the United coordination, illustrated significantly lower readmissions at Kingdom [41]. 30, 60 and 90 days, and reduced mortality at over 180 days [32]. Similarly, a transitional case management programme 13 European Geriatric Medicine Patient and caregiver education or coaching (n = 65) Almost Several intermediate care interventions delivered at all transitional care interventions included patient and/or home reported no evidence on length of hospital stay [56, carer education or coaching. There was a specific focus on 57] or reduced hospital readmission rates [56, 58–60]. How- medication management in half of the studies while the ever, many combined interventions had positive effects on others investigated the effects of coaching and support to reducing short-term and long-term (re)hospitalisation rates prevent additional treatment or review. Results in relation [61–69] reducing ED visits [65], improving quality of life to costs and readmissions were generally positive [42–44]. [61], and reducing costs [69]. Other outcomes included improvements in patient satis- Due to heterogeneity between studies, the interventions faction [45–47], quality of life [47, 48], improved infor- were grouped by the professionals supporting the interven- mation sharing and communication with members of the tions and their approach to care (Table 3). healthcare team and self-management [49, 50], as well as improved self-rated health and self-efficacy [47, 51]. Professionals delivering the interventions Decision support systems (n = 5) Electronic health records Interdisciplinary support with rehabilitation (n = 19) Inter- and patient information tools were used in most studies; disciplinary rehabilitation was included in 46% of the inter- however, few (n = 5) described specific decision support mediate care interventions at home. Many were geriatrician tools as the main element of their intervention. Although or physician-led programmes with collaboration of a team they provided mixed evidence on readmissions [52–54], of nurses, allied health professionals, and social care work- there were positive outcomes in relation to healthcare ers, and employed a comprehensive geriatric assessment adherence and quality of care [54, 55]. For example, a RCT approach. Their focus was on improving function in middle- implementing electronic transfer of patient discharge forms aged and older adults and re-able them to be independent in reported improved post-discharge outpatient follow-up rates their ADL. For example, an early supported discharge with in a diverse group of patients (mean age 58) admitted to a an intensive multidisciplinary community rehabilitation small community teaching hospital in the USA [55]. Another programme in England [13] reduced mean length of hos- study in the USA, deploying a transitional care bundle using pital stay by nine days and led to improved ADL and psy- patient-centred electronic data collection tools, supported chological well-being in older adults aged ≥ 65 (median age the spread of transitional care across multiple sites and 80). Similarly, an Australian study [62] reported improve- reduced medication errors in patients with a mean age of ments in instrumental ADL scores from a combined nurse 54, half of whom had a high risk of readmission [54]. and physiotherapy intervention at home delivered to 128 participants aged ≥ 65 (mean age 78). Intermediate care delivered at home Interdisciplinary support without rehabilitation Forty-one studies of intermediate care delivered at home (n = 12) Half of the interdisciplinary programmes did not were identified with thirteen studies conducted in North deliver a rehabilitation intervention but used combined America, 12 in Australia or New Zealand, 11 in Europe, approaches including time-limited case management usu- four in Singapore and one in Thailand. While 12 studies had ally by a trained nurse. Those were mostly from the USA a focus on medication reconciliation and review, all com- (n = 5) and Singapore (n = 3), followed by a few European bined several interventions including telephone advice and countries. For example, Hernández et al. [70] reported support, coaching for self-management and recovery, and reduced in-hospital days following a hospital outreach tel- follow up care. emedicine monitoring service for a large group of patients with chronic illnesses (n = 4165). Furthermore, all patients, Table 3  Number of studies reporting intermediate care interventions delivered at home (alone or in combination) according to the profession providing the intervention Profession Patient/carer Telephone Home visits Rehabilitation Medi- education support cines review Interdisciplinary (support with/without rehabilitation) (n = 31) 28 31 31 31 10 Nurse-led (n = 8) 8 8 7 0 1 Care coordinators (majority are registered nurses and medical 1 1 1 0 0 social workers) (n = 1) Paramedic-led (n = 1) 1 1 1 0 1 13 European Geriatric Medicine carers and health professionals involved in the programme Many investigated the effect of having beds dedicated to expressed high levels of satisfaction (98%) with the service. rehabilitation in community hospitals or residential care On the other hand, intermediate care at home for recovery units. For example, a discharge to intermediate care hos- and self-management illustrated mixed outcomes for ADL pital intervention resulted in fewer days spent in inter- and IADL scores. A transitional care bridge programme mediate care beds during a 1-year period [77]. The most delivered by a transitional care nurse and geriatrician, with- frequently reported outcome was hospitalisation, with 11 out rehabilitation, showed no effect on ADL functioning but studies reporting reduced length of stay or readmissions. decreased 6-month post-hospitalisation risk of death [7]. Three out of five studies considering long term care as their endpoint observed reduced institutionalisation [78–80]. Single profession led interventions (n = 10) Ten studies All the facilities aimed to ensure recovery and provide included uni-disciplinary support, mostly nurse-delivered rehabilitation via teams consisting of nurses, allied health interventions. They were mostly associated with positive professionals, or social care workers. Since there were dif- outcomes related to hospital utilisation and readmissions. ferences in relation to the content of the services, the tim- For example, an extended transitional case management ing of transfer, and support provided for staff members, the programme delivered by an advance nurse practitioner interventions were grouped according to several features. decreased 3-month rehospitalisation and total hospital days, resulting in decreased health care costs [66]. Simi- Assessment and rehabilitation (n = 11) larly, support for self-management and coaching by a nurse coordinator reduced rehospitalisation and ED attendance at Eleven studies implemented interdisciplinary rehabilitation 4–6 weeks post-discharge and increased quality of life and via in-reach support or in patient facilities (community hos- self-rated health [71]. pitals). Most of the rehabilitation activities were delivered on site or by telephone advice by interdisciplinary teams Approach to care led by physicians. The main outcomes included reduced hospitalisation and improved function. For example, tele- Crisis response or hospital admission avoidance phone-based medical consultations delivered by telephone (n = 7) Seven studies reported outcomes of hospital avoid- to support on-site care teams decreased hospital costs and ance or crisis response models, while some of them were shortened the length of hospital stay [81]. Another interven- built on an established early supported discharge service. tion by a community hospital providing intermediate care They had limited evidence on cost effectiveness [72] but closer to home and to social and care networks increased reported positive outcomes for patients and caregivers [3, independence and reduced mortality at 12 months [82, 83]. 72–74]. For example, a nurse-led multidisciplinary hospi- tal at home intervention via a hospital outreach programme Rapid transfer from acute care (n = 3) increased patient satisfaction and decreased Caregiver Strain Index scores [72]. Despite the fact that this hospital Three studies conducted in different community settings at home service was not cost effective, this was explained addressed early transfer from acute care settings to bed- as being due to not operating the service at its full capacity. based intermediate care. In general, they had positive effects Avoided costs were not reported [72]. on function and independence [79, 84]. For example, Young and colleagues [84] reported that early transfer to a com- The setting for follow‑up Except one, all intermediate care munity hospital for older patients with complex care needs at home interventions implemented home visits. Follow-up improved their ADL. services delivered via home visits during the post-discharge period were associated with improved communication Education and training for existing staff (n = 3) [56] and patient satisfaction with care [75]. In addition, compared to outpatient provider visits, home visits within Three studies considered the effectiveness of education for a week following discharge from a skilled nursing facility staff members in bed-based intermediate care units. Their (SNF) reduced the risk of 30-day rehospitalisation [76]. outcomes included reduced readmissions and ED visits [85, 86]. For example, education and training for SNF staff mem- Intermediate care delivered in a community bers who coordinate discharges reduced 30-day rehospitali- hospital, care home or post‑acute facility sation and enhanced patients’ preparedness for discharge [86]. Fourteen studies reported the effectiveness of bed-based intermediate care. These were mostly from Europe (n = 8), followed by North America (n = 5) and Australia (n = 1). 13 European Geriatric Medicine Discussion admissions, function, and healthcare costs. Evidence was strongest for discharge supported by an interdisciplinary This scoping review provides an analysis of the effectiveness team and rehabilitation at home. This outcome was also of a wide range of intermediate care including transitional encouraging for hospital avoidance of middle-aged and care models for middle-aged and older adults. Since they older adults but there was a limited number of empiri- were conducted in many different care settings, applied dif- cal studies to support this evidence. In practice settings, ferent inclusion criteria and evaluated a range of different both early supported discharge and intermediate care at outcomes (i.e. re-hospitalisation, ED admissions, and health- home are provided by services considering the individu- care costs as well as function), the studies were inherently alised needs of the patients and families. A systematic heterogeneous. Given this, it was challenging to identify and (Cochrane) review of 16 RCTs for admission avoidance summarise a common pattern for effectiveness and value, using hospital at home models [90] concluded that if this questioning the generalisability of the overall findings for type of service provides the option of hospital transfers service planning and clinical practice. Nevertheless, follow- when needed, it could be an effective alternative to hos- ing further analyses, we were able to synthesise the results pital care. Services providing early supported discharge and classify and group services under four different models can offer crisis response as well as hospital at home alter- of care: hospital-based transitional care, transitional care natives, which aid building confidence and capacity in interventions, intermediate care at home and bed-based patients and their families and/or informal caregivers for intermediate care, the findings of which are discussed in managing clinical risks. However, more evidence in this turn below. area is needed. Hospital-based transitional care was described in a small Shepperd et al. [91] reported in their Cochrane review number of studies that reported mixed results in relation that early discharge to a hospital at home model is a cost- to reductions in hospital readmission of middle-aged and effective alternative to usual care and it also aids improve- older adults, for all disciplines that conducted a planning ments in health. However, a more recent version of this and coaching based transitional care intervention. In the lit- systematic review [92] concluded that although early erature, a Cochrane review by Griffiths et al. [15] reported discharge hospital at home services are cheaper options limited evidence for the effectiveness of nursing-led units compared to inpatient care, there is no strong evidence for for care transitions. Although there were improved processes their economic efficiency or support for improvements in and positive outcomes for preparing patients for discharge health. Although we found some evidence for cost benefits within those units, more research was recommended to prove and positive outcomes for intermediate care at home, more their effectiveness. In our scoping review, the strongest evi- research is needed to identify cost-effectiveness at scale. dence for effectiveness and costs was from interventions for Bed-based intermediate care interventions reported older adults utilising a multidisciplinary Comprehensive reduced readmission rates and length of hospital stay, Geriatric Assessment (CGA) [87], where €519 was saved although few reported reduced admissions to long-term per person and ED or hospital (re)admissions were reduced institutional care. Enhanced specialist team support by 7.5% over three months post-discharge. was most likely to be effective, however, there was no evi- Transitional care interventions in both hospital outreach dence to specifically identify the ideal provider or opti- and community settings illustrated positive outcomes includ- mal care setting. In addition, no studies made comparisons ing positive patient experience, self-management, self-effi- between intermediate care provided in different settings cacy, and self-rated health. Benefits were also observed at such as a community hospital, nursing facility, residential the healthcare system level with reductions in early hos- care home, or transitional care unit. pital readmissions as well as ED admissions. Transitional This paper has a number of strengths and weaknesses. care interventions can bridge the gap between acute care This scoping review was conducted by academics and and community settings and so ensure the continuity of clinicians from a variety of disciplines across multiple care [88]. They can also help address the changing needs European countries providing an international and inter- of middle-aged and older adults at post-discharge periods disciplinary standpoint. A broad perspective on the tran- [89]. We identified that post-discharge telephone follow-up sitional and intermediate care interventions was ensured was a low-cost intervention that reached a high volume of since no restrictions were placed on the setting or level patients in transitional services yet the evidence for their of evidence. Despite these factors, this review has some effectiveness is limited. limitations. Firstly, the heterogeneous nature of the inter- Intermediate care at home showed benefits for ventions resulted in barriers to data synthesis, which did short-term and long-term re-hospitalisation rates, ED not make it possible to perform a systematic review and meta-analysis. To overcome this issue, the data were clas- sified according to the timing and setting of interventions 13 European Geriatric Medicine and synthesised according to their principal elements. Sec- reported in the literature, there is a need for systematic ondly, given our broad focus on middle-aged and older reviews and meta-analyses with a specific focus on high- adults, we did not include condition-specific interventions, quality experimental studies and in particular healthcare set- such as stroke rehabilitation (e.g. ESD for stroke). We did, tings, which may allow more robust comparisons between however, identify and include three studies [59, 60, 93] previously reported interventions. deploying interventions designed for frail older adults. Once again, these interventions were markedly different in their approach. Author contributions Design and planning DS, AH, ROC, AMC. Screening of titles and abstracts: DS, AH, MOD, MOS, AMC, LLS, CAC, RRA. Data extraction: DS, AH, MOD, MOS, LLS. Data analy- Intermediate care and COVID‑19 sis: DS, AH. Drafting of manuscript: All. Proofreading and confirma- tion of final version of manuscript: All. Although this review includes papers published before the ongoing global COVID-19 pandemic, it is important to Funding This work was completed as part of the Joint Action on Frailty Prevention ‘grant number 724099/ADVANTAGE’, which has acknowledge the important role intermediate care is playing received funding from the European Union’s 3rd Health Programme in managing those with and without COVID-19. COVID-19 (2014–2020). is known to disproportionally affect older adults, particularly those who are frail [94, 95]. Worldwide, alternatives to hos- Data availability The relevant data can be provided to interested indi- pital treatment have been scaled-up during the pandemic viduals on request. through virtual consultations and access to intermediate care at home and in step-up and step-down facilities. Although Compliance with ethical standards the challenges and effectiveness of delivering intermediate Conflict of interest On behalf of all authors, the corresponding author care during this pandemic are yet to be investigated, it fea- states that there is no conflict of interest. tures in pathways for those recovering from COVID-19 who require support and rehabilitation as they transition to home Disclaimer The content of this article represents the views of the or long-term care [96]. authors only and is their sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the informa- Conclusions tion it contains. Ethics approval Not applicable. 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