Research Article  |   February 2019
Care Transition Processes to Achieve a Successful Community Discharge After Postacute Care: A Scoping Review
Author Affiliations
  • Natalie E. Leland, PhD, OTR/L, BCG, FAOTA, FGSA, is Associate Professor, Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA; nel24@pitt.edu
  • Pamela Roberts, PhD, OTR/L, SCFES, FAOTA, CPHQ, FNAP, FACRM, is Executive Director and Professor, Department of Physical Medicine and Rehabilitation, and Executive Director Academic and Physician Informatics, Cedars-Sinai Medical Center, Los Angeles, CA.
  • Roxanne De Souza, OTR/L, is Student, University of Southern California, Los Angeles.
  • Sun Hwa Chang, OTR/L, is Student, University of Southern California, Los Angeles.
  • Kruti Shah, is Student, University of Southern California, Los Angeles.
  • Marla Robinson, Msc OTR/L, BCPR, FAOTA, is Assistant Director, Department of Therapy Services, The University of Chicago Medical Center, Chicago, IL.
Article Information
Advocacy / Evidence-Based Practice / Health and Wellness / Rehabilitation, Participation, and Disability / Research Articles
Research Article   |   February 2019
Care Transition Processes to Achieve a Successful Community Discharge After Postacute Care: A Scoping Review
American Journal of Occupational Therapy, February 2019, Vol. 73, 7301205140p1-7301205140p9. doi:10.5014/ajot.2019.005157
American Journal of Occupational Therapy, February 2019, Vol. 73, 7301205140p1-7301205140p9. doi:10.5014/ajot.2019.005157
Abstract

Readmissions to health care facilities are undesirable outcomes that indicate the quality of the care transitions. Although there is a growing evidence-base for preventing readmissions, the focus has been on acute care. Postacute care (PAC) patients are often excluded from these studies, and thus there is limited evidence guiding practitioners’ efforts to facilitate an effective community transition after PAC rehabilitation. To provide direction for PAC research and clinical practice, this scoping review summarizes current community transition interventions and identifies practices that facilitate successful community discharge. Thirteen care processes emerged from 35 studies, of which 5 were included in at least 60% of the studies, including coaching on the care transition process, medical self-management, medication self-management, scheduling follow-up medical services, and telephone follow-up. These findings can inform the development, evaluation, and implementation of PAC community transition interventions.