Background

Older people are at risk of low quality of life due to (comorbid) health conditions that can come with advanced age [1, 2]. As a result, care for complex health conditions across care settings, and transitions between these settings are often needed [3]. However, transitional care is often poorly handled [4, 5] and can lead to negative outcomes, low care satisfaction, and care inefficacy [6, 7]. Though older people should be central in such transitions, they report confusion, a lack of control, and the inability to have their say in the care transition decisions [8,9,10]. At the same time, informal caregivers report unsatisfactory communication with the older person they care for, within their families, as well as with health professionals, all leading to hindered transitional care decision-making [8]. A focus on the empowerment of older people and informal caregivers in the transitional care decision-making thus becomes relevant [11, 12].

The World Health Organization defines empowerment as “a process through which people gain greater control over decisions and actions affecting their health” [13]. In line with this definition, alternative empowerment interventions can be considered [14,15,16]. However, an overview of interventions for empowering older people and informal caregivers in transitional care decision-making, and their effects, is not available from the literature.

Thus, we aim to provide a systematic overview of the literature concerning the evaluation of interventions designed to empower older people and informal caregivers in transitional care decision-making, and to explore their impact.

Methods

We performed a systematic review (Prospero Protocol CRD42020167961), and report its results in line with the PRISMA [17] guidelines.

Review methods

PubMed, EMBASE, Web of Science, PsycINFO, and CINAHL were searched from the inception of the databases up until April 2022. Concepts for the search strategy were ‘old age’, ‘informal caregivers’, ‘involvement in decision-making’, ‘transitional care’, and ‘home’ as a location for either the start or the end of the transition. The search strategy was developed by all authors and search strings were built, pre-tested, and finalized with the help of a professional information specialist (see supplementary file 1).

During the process of searching and including literature we were in contact with various authors on the topic of transitional care (e.g. to obtain full text or additional info). Potentially relevant publications suggested by these authors were also checked for their relevance.

Inclusion and exclusion criteria

Publications were included if they met the following criteria: (1) reports of empirical studies; (2) study participants (or at least 70% of them) aged 65+ and/or informal caregivers; (3) study participants facing a care transition departing from or returning to the older person’s home; and (4) reports should evaluate interventions that include empowerment in transitional care decision-making. Studies without empirical data were excluded. Language was not a reason for exclusion.

Study selection

The first author (LK) performed the searches and removed duplicates. The selection process was always performed by two independent researchers per publication, first based on titles and abstracts and then based on full text screening for the remaining articles. In case of disagreements, the researchers tried to reach a consensus or consulted a third researcher where necessary.

Quality assessment

Study quality was double blindly evaluated by two independent reviewers, using the relevant JBI-critical appraisal tools [18].

Data extraction

Data extraction was independently conducted by LK and TvA, and for publication year, country, interventions for empowerment in decision-making, design, sample, outcomes measured, and main results (Table 1). References to details on the study interventions were always checked in the process. Discrepancies in the extractions were discussed and resolved.

Table 1 Study characteristics (n = 10), interventions, outcomes assessed and main results
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Analysis and reporting

Given the limited number of studies and the considerable heterogeneity, a narrative descriptive analysis of the studies was performed and a short report was drawn-up.

Findings

Of 6476 unique records, full texts of 808 studies were screened. Eight of these were included. Two additional studies were retrieved through contacts with authors on the topic or screening the work of specific authors, resulting in a total of ten studies (total of 4642 participants) reporting on nine interventions (Fig. 1). The studies were three (cluster-) randomized controlled trials (RCTs), three non-RCTs, one retrospective comparative study, one before-after study, and two observational studies (Table 1).

Fig. 1
figure 1

PRISMA flow diagram for the identification, selection, and inclusion of studies

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Quality assessment

No studies were excluded based on quality. Overall, studies were of a reasonable quality in the light of the designs used. However, for most studies one or a few study aspects were unclear from the report, or received a negative score. (See supplementary file 2 for details).

The studies

Five out of the nine interventions addressed hospital discharge (Table 1). The other interventions focused on transitions from a short stay unit to outpatient/home care, people’s preferences for potential transfers in case of severely deteriorating health, and future housing decisions (i.e. living at home or in a residential care facility). The two latter studies were the only ones in which empowerment for decision-making was the central intervention. Empowerment was an element in a larger transitional care intervention in all other cases, where healthcare professionals were central in initiating and planning for transitions.

Intervention (elements) for empowerment included tools for considering and preparing for transitions, support from transition coaches, shared decision-making (SDM), and advanced care planning. Outcomes focused on intervention feasibility, use of care services, timeliness of arrangements, utility of the interventions, transition preparedness, and preferred place of death (Table 1).

Interventions and effects

Hospital discharge preparation tools were operationalized as planning manuals and checklists that encourage people to consider all aspects of hospital discharge, necessary arrangements, and their personal discharge readiness. The two studies evaluating such tools as a single intervention showed peoples’ appreciation for the tools with a view to their relevance and utility, but indicated no effects on the quality of discharge [22, 27].

A combined intervention of a discharge preparation tool and support of a transition coach was evaluated in two studies [20, 21]. In these studies, the transition coach offered guidance and continuity of care at several points in the transition process. Results showed reduced use of emergency department services and fewer re-hospitalizations, but not consistently for all comparisons.

Shared decision-making interventions were central in five studies [19, 24,25,26, 28]. Four studies evaluated SDM on transition plans and included identifying problems and solutions, person-centered mutual goals development, and ongoing evaluation and follow-up [24, 25, 28]. Results included shorter hospital stays, fewer discharge delays, improved mental (but not physical) quality of life, and positive views on the older people’s involvement in discharge processes. Feasibility results from one of these studies indicated that coordination processes and actual involvement did not always happen. In one of the studies, inter-professional SDM training and use of a decision guide, were the core intervention elements [19]. This study reported a higher proportion of informal caregivers reporting an active role in the decision-making as compared to control, but not statistically significantly so, and no effects on secondary outcomes were found.

Advance care planning for preferred place of death [23], was a very brief intervention that asked people in palliative care to document their preferred place of death. In this retrospective comparative study, the intervention was associated with dying at home more often (as compared to people with no advanced care planning), and a positive correlation between preferred place of death and actual place of death was found. However, statistics for these results were incomplete in the study report.

Discussion

Our review identified limited research on interventions for the empowerment of older people and informal caregivers at the time of transitional care decision-making. Shared decision-making, advanced care planning, and (combined) hospital and skilled nursing facilities discharge preparation tools and support from a transition coach have all been used for such empowerment. However, variability in interventions, study designs and outcomes assessed, and inconclusive results do not allow for drawing conclusions on their effectiveness.

Two interventions primarily focused on empowerment in decision-making and assessed relevant outcomes for empowerment [19, 23], while all of other interventions included elements of empowerment in decision-making in a larger multi-component intervention. This was also reflected by some of the primary outcomes for the intervention evaluation (e.g., looking at re-hospitalizations and emergency department visits, rather than person-centered outcomes). Such variability of outcomes assessed for the empowerment of older people was also reported by Shearer et al. [29]. Their review on empowerment of older people in taking health-related decisions, showed that outcomes assessed were highly variable, even when empowerment was conceptualized in the same way [29]. These and other findings illustrate that there is no generally accepted measurement of people’s empowerment [30], even though there is a clear need for a stronger emphasis on person-centered empowerment [14, 29].

This review’s strength lies in its exhaustive literature searches and rigorous inclusion and data extraction processes. However, a major limitation is that we could not synthesize findings, due to the high variability in interventions, designs used and outcomes assessed. Instead, we categorized the interventions into logical groups, and highlighted the different interventions and their outcomes.

In conclusion, this brief report indicates a lack of research on how to empower older people and their informal caregivers in transitional care decision-making. Furthermore, empowerment for decision-making is insufficiently central to transitional care interventions and effects on actual empowerment are mostly not assessed. As a result, conclusions on how best to empower older people and informal caregivers in transitional care decision-making cannot be drawn.