Published on in Vol 5, No 2 (2022): Apr-Jun

Preprints (earlier versions) of this paper are available at, first published .
Recommendations for the Design and Delivery of Transitions-Focused Digital Health Interventions: Rapid Review

Recommendations for the Design and Delivery of Transitions-Focused Digital Health Interventions: Rapid Review

Recommendations for the Design and Delivery of Transitions-Focused Digital Health Interventions: Rapid Review


1Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada

2March of Dimes Canada, Toronto, ON, Canada

3Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada

4Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada

5Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada

6Department of Medicine, University of Toronto, Toronto, ON, Canada

7Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada

8Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

9St. John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

10Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy

11Gerstein Science Information Centre, University of Toronto, Toronto, ON, Canada

12Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel

13Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada

14School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

Corresponding Author:

Hardeep Singh, MScOT, PhD

Department of Occupational Science & Occupational Therapy

Temerty Faculty of Medicine

University of Toronto

500 University Avenue

Toronto, ON, M5G 1V7


Phone: 1 416 946 3724


Background: Older adults experience a high risk of adverse events during hospital-to-home transitions. Implementation barriers have prevented widespread clinical uptake of the various digital health technologies that aim to support hospital-to-home transitions.

Objective: To guide the development of a digital health intervention to support transitions from hospital to home (the Digital Bridge intervention), the specific objectives of this review were to describe the various roles and functions of health care providers supporting hospital-to-home transitions for older adults, allowing future technologies to be more targeted to support their work; describe the types of digital health interventions used to facilitate the transition from hospital to home for older adults and elucidate how these interventions support the roles and functions of providers; describe the lessons learned from the design and implementation of these interventions; and identify opportunities to improve the fit between technology and provider functions within the Digital Bridge intervention and other transition-focused digital health interventions.

Methods: This 2-phase rapid review involved a selective review of providers’ roles and their functions during hospital-to-home transitions (phase 1) and a structured literature review on digital health interventions used to support older adults’ hospital-to-home transitions (phase 2). During the analysis, the technology functions identified in phase 2 were linked to the provider roles and functions identified in phase 1.

Results: In phase 1, various provider roles were identified that facilitated hospital-to-home transitions, including navigation-specific roles and the roles of nurses and physicians. The key transition functions performed by providers were related to the 3 categories of continuity of care (ie, informational, management, and relational continuity). Phase 2, included articles (n=142) that reported digital health interventions targeting various medical conditions or groups. Most digital health interventions supported management continuity (eg, follow-up, assessment, and monitoring of patients’ status after hospital discharge), whereas informational and relational continuity were the least supported. The lessons learned from the interventions were categorized into technology- and research-related challenges and opportunities and informed several recommendations to guide the design of transition-focused digital health interventions.

Conclusions: This review highlights the need for Digital Bridge and other digital health interventions to align the design and delivery of digital health interventions with provider functions, design and test interventions with older adults, and examine multilevel outcomes.

International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2020-045596

JMIR Aging 2022;5(2):e35929




Hospital-to-home transitions can be a challenging time for older adults [1-10] owing to the high risk of adverse events, including medical errors, hospital readmission, and death [4,7,11,12]. It has been noted that almost half of the adverse events experienced during these transitions could be prevented or minimized [4,7,11,12]. Furthermore, pressures facing health care systems have resulted in decreased lengths of hospital stay, leading to patients being discharged quicker and sicker and an increased risk of hospital readmissions and poor health outcomes [13-16]. The costly and negative impacts of poor transitions have made transitions a high priority for the health care system and prompted significant efforts to improve hospital-to-home transitions [17].

Multidisciplinary teamwork is one of the critical aspects of high-quality continuity of care [18]. Facilitating successful hospital-to-home transitions involves team effort because multiple tasks must be completed by various health care providers across inpatient and community settings [16]. Information-sharing and communication issues combined with a lack of role clarity can cause poor continuity of care and service fragmentation during transitions [16,19-22].

Improving hospital-to-home transitions entails improving communication and coordination among multiple providers and across multiple health care settings [23,24]. Rennke and Ranji [17] have suggested that successful hospital-initiated transitional care programs include a “bridging” strategy with pre- and postdischarge interventions. Although numerous transitional care models and strategies have been proposed [17,25-31], they require considerable resources, such as a dedicated transition provider, because of the additional work required [16,17,32,33]. However, this may not be a feasible or affordable solution for health care organizations because organizations tend to seek solutions that are “high-value, low-cost” [17].

The use of digital health technologies is an approach used to facilitate safe hospital-to-home transitions because they can augment provider roles and functions during transitions while attempting to minimize costs [34-36]. Many digital health technologies have been proposed to mitigate transition issues experienced by older adults and their caregivers and facilitate efficiency and coordination in the discharge process. For example, digital health interventions can be used to monitor older adults’ symptoms [37], provide educational material and discharge instructions [38,39], and facilitate timely information sharing among providers across settings [40]. However, digital health technologies, in general, have not been well integrated into clinical practice settings because of persistent barriers, including poor fit with providers’ roles and functions because digital health interventions add additional functions to the existing workloads of providers [41,42]. An improved understanding of which providers are involved in care transitions and how the technologies can support their existing provider functions may address some of these implementation barriers [43,44].


Despite the vast landscape of digital health technologies, there have been limited syntheses of digital health interventions used to support hospital-to-home transitions and the lessons learned from their implementation. This information is critical to avoid duplication of problematic factors that can limit the uptake of digital health technologies within the development and implementation of new transition-focused digital health interventions. To guide the development of an information communication technology to support transitions from hospital to home (the Digital Bridge intervention [45]), the specific objectives of this review were as follows:

  • Understand the various roles and functions of health care providers supporting hospital-to-home transitions for older adults, allowing future technologies to be more targeted to support their work.
  • Describe the types of digital health interventions used to facilitate the transition from hospital to home for older adults and elucidate how these interventions support the roles and functions of providers.
  • Describe the lessons learned from the design and implementation of these interventions.
  • Identify opportunities to improve the fit between technology and provider functions within the Digital Bridge intervention and other transition-focused digital health interventions.

A rapid review methodology [46] was suitable for this review because we intended to generate a timely overview of the existing landscape of digital health technologies. This rapid review was based on our previously published protocol [43].

Phase 1: A Selective Literature Review to Understand Roles and Functions of Health Care Providers Supporting Hospital-to-Home Transitions

A selective review [47,48] was undertaken using MEDLINE (Ovid) and Google Scholar on September 19, 2020, to provide greater insights and clarity regarding health care providers’ roles and their essential functions [44] in supporting hospital-to-home transitions. These 2 databases were selected for the following reasons: (1) they are multidisciplinary, (2) MEDLINE (Ovid) is a widely used database to identify peer-reviewed health-related literature [49], and (3) Google Scholar is a “powerful addition to other traditional search methods” to help identify known studies [50]. A selective literature review limited the search to “key studies that significantly contribute to our understanding” [47,48]. The search terms included concepts related to navigation, hospital-to-home transition, and older adults [43]. Any study design published in English that identified a role and function related to a hospital-to-home transition was included. The following data were extracted from relevant articles:

  1. What provider role (ie, job title) is identified?
  2. What is the provider’s function (ie, responsibilities related to supporting a hospital-to-home transition)?

Key roles were identified, and their functions were thematically analyzed on NVivo 11 (QSR International) using inductive thematic analysis [51]. Subsequently, the coded functions were organized according to the 3 categories of continuity of care: informational, management, and relational [52]. These categories were used because they could create a shared understanding and language for continuity of care across disciplinary and organizational boundaries [52].

Phase 2: Identifying Digital Health Technologies Supporting Transitions

Literature Search

In phase 2, MEDLINE (Ovid), CINAHL (EBSCO), and Embase (Ovid) were searched on November 26, 2020, to identify literature on digital health interventions supporting the transition from hospital to home for older adults (Multimedia Appendix 1). These databases were selected because they (1) could identify health-related literature and (2) were determined by our research team (including a medical librarian HVC) to be appropriate for the scope of our search [43]. The review adhered to the PRISMA-S (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Literature Search) checklist [53]. The reference lists of some included articles (n=20) were hand searched, and content experts (n=6) were consulted to identify additional studies.

Study Selection

The search results were uploaded to the Covidence website. On the basis of the inclusion and exclusion criteria (Multimedia Appendix 2 [54,55]), each article’s title and abstract were screened by a single reviewer from the screening team (HS, TT, KK, RT, DP, MH, CMJ, AA, or JXN), followed by a full-text review conducted independently by 2 reviewers from the screening team. Any conflicts were resolved through team discussions. Studies were included if they tested a digital health intervention that supported a hospital-to-home transition for older adults and were published in or after 2010. For this review, an intervention that supported a hospital-to-home transition had to have recruited participants before their hospital discharge and continued in the home or community setting. The studies had to include ≥1 older adult but did not need to focus on older adults exclusively. No limits were imposed on study design to ensure that we included relevant studies, but articles had to report findings from empirical studies. Given that we intended to inform recommendations for the Digital Bridge intervention [45], a high-technology intervention for use in a “high-income country,” strictly telephone-based interventions, and interventions tested in a “low-income country” were excluded [54].

Data Extraction

The following data were extracted from the articles using a customized form informed by the Template for Intervention Description and Replication framework [56]: author details; country and year of publication; sampling strategy; inclusion and exclusion criteria; the medium of technology, function of technology, and who provided the intervention; study findings; and limitations and future directions. Data regarding intervention effectiveness were not extracted, reported, or synthesized in this review because this was outside its purpose, scope, and intent [57].

Data Analysis

We descriptively reported study characteristics and qualitatively analyzed data using a thematic analysis [51]. We first analyzed each study’s discussion using data-driven codes to identify lessons learned. We then coded data deductively by grouping the technology functions according to the 3 categories of continuity of care described by Haggerty et al [52]. The technology functions and providers involved in intervention delivery were compared with the provider roles and functions identified in phase 1.

Phase 1

The literature review revealed several provider roles that commonly support hospital-to-home transitions (Textbox 1). In addition to the professional roles of allied health clinicians, pharmacists, nurses, and physicians, several navigation-specific roles were noted. Key provider functions during transitions are presented in Textbox 2. Of note, roles and functions supporting transitions differed by type of institution and many roles performed overlapping functions.

Provider roles identified as engaged in facilitating hospital-to-home transitions.

Navigation-specific roles: providers with known navigation-related role titles [58]

  • Advanced practice navigator, care manager (could be a nurse, social worker or clerical staff [59]), care or program coordinator, care transition nurse, case manager, discharge coordinator, discharge liaison nurse or liaison nurse, discharge planner or facilitator or discharge planning nurse (typically a social worker or nurse [60]), case manager, discharge coordinator, geriatric care manager, guided care nurse, intensive geriatric service worker, nurse navigator, post–acute care coordinator (typically allied health or nurse [61]), patient navigator, surgical coordinated transitional care program nurse, transition coach

Allied health

  • Occupational therapist, physiotherapist, social worker


  • Hospital or community pharmacist


  • Trained nurse (trained in device use), research nurse, cancer nurse specialist, telemedicine nurse, rehabilitation nurse, nurse tutor, nurse practitioner, registered nurse, chronic obstructive pulmonary disease nurse, clinical nurse specialist, community nurse, telemedicine nurse


  • Community physician (eg, primary care physician, ambulatory physician, or community physician), hospital physician (eg, hospitalist, resident, or most responsible physician), specialist
Textbox 1. Provider roles identified as engaged in facilitating hospital-to-home transitions.
Key functions performed by providers during the hospital-to-home transitions.

Informational continuity: “The use of information on past events and personal circumstances to make current care appropriate for each individual” [52]

  • Communicate or liaise: communication or liaising with patients, caregivers, and other providers
    • Ensure the flow of information across multidisciplinary teams in the same or different sectors [62,63]. Advise and share relevant information about the patient with other providers (eg, primary care provider) [64-67]. Coordinate with other providers to ensure that services, resources, and equipment are set up for the patient. Make connections with community-based services and resources [68,69]. Communicate with patients and caregivers promptly [63]. Inform patients and caregivers and family when and how they will be contacted and whom to follow-up with if they do not receive follow-up [60,68,70,71]
  • Educate: providing education to patients and caregivers
    • Educate patients about condition, disease management, symptoms, adverse events or red flags, symptom management, dietary recommendations, medication instructions, general condition or health, explain care protocols [25,68,72-81], reinforce education (eg, teach-back strategies) [82], and provide verbal or written instructions and demonstrations [63,83]
  • Knowledge: providers having relevant knowledge
    • Have solid knowledge about disease and treatment, community services, where patients can seek support, and the best practices [79]. Be familiar with available community services and their eligibility
  • Support or resource: providing relevant information to patients and caregivers
    • Provide informational or social support and personalized hospital-to-home support [83,84]
  • Counsel (fell within 2 different categories): providing advice and recommendations to motivate behavior change
    • Provide medication, rehabilitation, dietary, or emotional counseling to patients and caregivers to motivate behavior change [79-81,85]
  • Document: documenting relevant information accurately
    • Document all actions and entire plan to ensure timely information exchange between providers and ownership of the accuracy and completeness of the information [65,86]

Management continuity: “A consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs” [52]

  • Confirm and verify: confirming and verifying that appropriate processes and procedures were carried out to ensure continuity of care
    • Confirm that discharge summaries have complete information about a patient [87] and are sent to the team [75]. Ensure that follow-up appointments and services have been scheduled [65,75,78,88]. Confirm that patients and caregivers and families understand discharge instructions and that logistics are in place in preparation for discharge [75]. Verify that the appropriate practitioners are involved [75]
  • Plan: creating a personalized care plan for patients
    • Create or contribute to a patient’s care plan based on knowledge of the patient’s individual needs and goals [89]
  • Refer: referring patients and caregivers to appropriate services and resources
    • Refer patients to appropriate community services and resources to maintain continuity of care after discharge (eg, transportation) [62,72,90-93]
  • Assist in navigation: helping patients and caregivers to navigate the health system
    • Assist patients in navigating through complex health systems and discharge pathways [62,72,90-93]
  • Advocate: advocating patients’ access to appropriate resources and services
    • Advocate for access and entry to appropriate health and social services across settings and providers to ensure that patients’ needs are met, and break down health system and communication barriers [58,63,94]
  • Follow-up: following up with patients and caregivers after discharge
    • Postdischarge follow-up and outreach with patients to identify unmet needs [95]
  • Arrange or set up: facilitating access to different providers, services, and resources
    • Coordinate with different providers and services to arrange and organize timely access to postdischarge appointments and services, including primary care, medication delivery, medical devices, and transportation. Assist patients and caregivers and families in meeting their health care needs (eg, assistance completing forms) [25,58,61,62,90,91,96-98]
  • Assess patients’ needs: assessing patients’ various needs to support safe transitions
    • Have a comprehensive knowledge of the patients’ care needs (eg, “patient’s medical, functional, cognitive, affective, psychosocial, nutritional, and environmental status” [76,99]) and goals to inform care and discharge plan through assessment findings [58,63,100]. Assess patients’ needs for home care and community support and resources, and identify and address potential medication adherence issues to prevent readmission [63,67,76,78,83,95,101,102]
  • Direct care provision: clinical intervention
    • Provide in-person and hands-on clinical care (eg, medical, nursing, or rehabilitation intervention) [58]
  • Manage: manage health and social care and needs during transitions
    • Be a manager of the patient’s care and discharge pathways [72,89]
  • Monitoring: activities conducted to monitor patients’ status after discharge
    • Monitor patients for medical, health, physical, or functional status declines or the inability to self-manage their condition [86,87]. Monitor the results of medical tests and treatment adherence [89]. Conduct ongoing evaluations of the discharge plan and patient and caregiver and family needs (eg, through home visits) and create a new action plan or refer to other providers if necessary [63,89]
  • Improve: improving care based on organizational quality improvement initiatives
    • Participate in quality improvement plans [59]
  • Prepare: preparing providers, patients, and caregivers for patients’ discharge
    • Prepare personalized discharge plans with the patient, caregiver and family, and providers and complete discharge preparation, including determining discharge location [62,89-91]. Prepare discharge hand-over sheets [75]. Prepare a community care plan [96]

Relational continuity: “An ongoing therapeutic relationship between a patient and one or more providers” [52]

  • Collaborate: work with patients, caregivers, and other providers to manage care
    • Collaborate with patients, caregivers and family, and other providers (eg, hospital physician-primary care physician) to create care plans [60,103]
  • Empower: facilitate patient and caregivers’ involvement in the case
    • Facilitate active participation of patients and caregivers and family in care and integrate them as full partners in decisions about treatment [60,85,89,104]
  • Counsel (2 categories): providing counseling to patients and caregivers in an understandable way
    • Provide individual medication counseling and ensure that patients can comprehend medication instructions and potential side effects of medication [80]. Provide emotional or dietary counseling and counseling regarding the patients’ rehabilitation needs to motivate behavior change [69,79,85]
  • Coaching: providing coaching and guidance to patients and caregivers
    • Provide clinical advice, troubleshoot problems, and provide coaching about self-management skills [72,85,104-106]. Answer questions regarding concerns or issues from patients or caregivers and family [107]. Inform patients about what to expect during the transition and provide tips on communication with providers [82]
  • Rapport: building relationships with patients and caregivers
    • Develop rapport and trusting relationships with patients and caregivers or family [25,98,108-110]
Textbox 2. Key functions performed by providers during the hospital-to-home transitions.

Phase 2


The phase 2 database search identified 29,359 articles. Additional articles (n=10) were identified from hand-searching reference lists of the included articles. After removing duplicates, 81.88% (24,048/29,369) remained for the title and abstract screening and 4.02% (967/24,048) met the criteria for full-text review. Of these 967 articles, 142 (14.7%) met the study inclusion criteria (see Figure 1 [111] for the PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] flow diagram). Table 1 provides details of the study characteristics.

The studies were conducted in multiple countries, most of them in the United States (Table 1). They were published between 2010 and 2020, with a growing rate of publications over the years (Figure 2).

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. Adapted from Moher et al [111].
View this figure
Table 1. Study characteristics.
StudyCountryMedical condition and intervention details
Amir et al, 2017 [112]IsraelCardiac (heart failure)
Ammenwerth et al, 2015 [113]AustriaCardiac (coronary heart disease)
Amroze et al, 2019 [114]United StatesNon–condition-specific criteria
Andikyan et al, 2012 [115]United StatesCancer (gynecologic cancer)
Arcilla et al, 2019 [116]United StatesMultiple chronic conditions (eg, congestive heart failure, chronic obstructive pulmonary disease, and diabetes mellitus)
Austin et al, 2012 [34]United StatesCardiac (congestive heart failure)
Avery et al, 2019 [117]United KingdomCancer (major abdominal surgery, including surgery for esophageal, gastric, or hepato-pancreato-biliary cancer)
Aziz et al, 2011 [118]United KingdomSurgery (abdominal surgery)
Backman et al, 2020 [119]CanadaOrthopedic (after hip fracture)
Barken et al, 2018 [120]NorwayRespiratory (chronic obstructive pulmonary disease)
Barnason et al, 2019 [121]United StatesCardiac (coronary artery bypass surgery or percutaneous coronary intervention)
Bednarski et al, 2019 [122]United StatesCancer (colorectal cancer surgery)
Belarmino et al, 2019 [123]United StatesCancer (radical prostatectomy)
Bernocchi et al, 2016 [124]ItalyNeurological (stroke)
Bernocchi et al, 2012 [125]ItalyMultiple conditions (chronic obstructive pulmonary disease, cardiac, dermatologic, diabetes, pulmonological, traumatic brain injury, and stroke)
Boeni et al, 2015 [126]SwitzerlandDiabetes
Book et al, 2013 [127]GermanyCancer (prostate, bladder, kidney, breast, or other types of cancer)
Bouwsma et al, 2018 [128]NetherlandsSurgery (gynecological surgery)
Bouwsma et al, 2018 [35]NetherlandsSurgery (gynecological surgery)
Campbell et al, 2019 [129]United StatesOrthopedic (total knee or hip arthroplasty)
Carrier et al, 2016 [130]FranceCancer (colorectal surgery)
Chang et al, 2020 [131]ChinaCancer (esophagectomy)
Chen et al, 2010 [132]AustraliaPatients admitted to the aged care hospital ward
Chen et al, 2019 [133]ChinaCardiac (chronic heart failure)
Chiang et al, 2012 [134]ChinaCardiac (chronic heart failure)
Cox et al, 2018 [135]United StatesMedical and surgical intensive care unit patients (receipt of mechanical ventilation for >48 consecutive hours and successful extubation before discharge)
Cox et al, 2019 [136]United StatesCardiac (cardiorespiratory failure)
Davis et al, 2015 [137]United StatesMultiple conditions (acute chronic disease)
Day et al, 2018 [138]United StatesOrthopedic (total joint arthroplasty)
Dendale et al, 2012 [139]United StatesCardiac (severe heart failure)
DeVito Dabbs et al, 2016 [140]United StatesSurgery (lung transplantation)
DeVon et al, 2010 [141]United StatesCardiac (coronary heart disease)
Dexter et al, 2013 [142]United StatesOrthopedic (total hip replacement)
Dorothy et al, 2016 [143]United StatesCardiac (cardiovascular surgery)
Duncan et al, 2018 [144]United StatesNeurological (stroke and transient ischemic attack)
Dunn et al, 2015 [145]United StatesPatients on medical or surgical units on warfarin
El-Kareh et al, 2012 [44]United StatesPatients with positive and untreated or undertreated blood, urine, sputum, or cerebral spinal fluid cultures
Evangelista et al, 2015 [146]United StatesCardiac (chronic heart failure)
Finn et al, 2011 [13]United StatesPatients on medical service
Fitzsimmons et al, 2016 [147]United KingdomRespiratory (chronic obstructive pulmonary disease)
Frail et al, 2016 [148]United States Patients taking ≥1 long-term medication
Gesell et al, 2019 [149]United StatesNeurological (stroke)
Gunter et al, 2018 [150]United StatesSurgery (vascular surgery)
Gurwitz et al, 2014 [40]United StatesPatients being discharged from an inpatient unit
Gustavell et al, 2019 [151]SwedenCancer (pancreaticoduodenectomy)
Gustavell et al, 2019 [152]SwedenCancer (pancreaticoduodenectomy)
Haynes et al, 2020 [153]United StatesCardiac (decompensated heart failure)
Heaton et al, 2019 [154]United StatesMultiple conditions (acute myocardial infarction, pneumonia, congestive heart failure, chronic obstructive pulmonary disease, or diabetes)
Heiney et al, 2020 [155]United StatesCardiac (heart failure)
Hewner et al, 2014 [156]United StatesMultiple conditions
Ho et al, 2016 [157]ChinaRespiratory (chronic obstructive pulmonary disease)
Holleck et al, 2017 [158]United StatesPatients admitted to medical service
Holt et al, 2011 [159]United StatesSurgery (plastic surgery)
Hu et al, 2014 [160]ChinaCardiac (percutaneous coronary intervention)
Jayaram et al, 2017 [161]United StatesCardiac (heart failure)
Jeungok et al, 2017 [162]United StatesOrthopedic
Jonker et al, 2020 [163]NetherlandsCancer (elective oncologic resection of a solid tumor)
Kamoen et al, 2020 [164]BelgiumNeurological (ischemic stroke)
Kang et al, 2019 [165]ChinaNeurological (stroke)
Karapinar-Çarkit et al, 2014 [166]NetherlandsPatients discharged from the cardiology and respiratory wards
Katz et al, 2016 [167]United StatesCancer (pancreatectomy)
Keeping-Burke et al, 2013 [168]CanadaCardiac (coronary artery bypass graft surgery)
Khan et al, 2018 [169]DenmarkCardiac (on- or off-pump coronary artery bypass graft or heart valve surgery)
Klement et al, 2019 [170]United StatesOrthopedic (total joint arthroplasty)
Kogut et al, 2014 [171]United StatesChronic medical conditions
Lacson et al, 2018 [172]United StatesRespiratory (pulmonary nodules)
Lafaro et al, 2020 [37]United StatesCancer (colorectal, gastric, pancreatic, and liver cancer surgery)
Lavu et al, 2019 [36]United StatesSurgery (pancreaticoduodenectomy)
Layton et al, 2014 [173]United StatesCardiac (coronary artery disease or congestive heart failure)
Lehnbom et al, 2014 [174]AustraliaPatients discharged from a hospital unit
Lin et al, 2020 [175]ChinaCardiac (coronary artery disease)
Lindhardt et al, 2017 [176]DenmarkPatients admitted to internal medicine units and at nutritional risk
Lowres et al, 2016 [177]AustraliaCardiac (cardiac surgery)
Luo et al, 2019 [178]ChinaOrthopedic (total hip arthroplasty)
Lyu et al, 2016 [179]ChinaCancer (head and neck tumor)
Madigan et al, 2013 [180]United StatesCardiac (heart failure)
Markle-Reid et al, 2020 [181]CanadaNeurological (stroke and multimorbidity)
Martirosov et al, 2020 [182]United StatesPatients admitted to hospital
Mathar et al, 2015 [183]DenmarkRespiratory (chronic obstructive pulmonary disease)
McCloskey et al, 2015 [184]CanadaPatients discharged from geriatric rehabilitation
McGillion et al, 2020 [185]Canada and United KingdomCardiac and major vascular surgery
Melholt et al, 2018 [186]DenmarkCardiac (ischemic heart disease or heart failure, including patients who had undergone coronary artery bypass or valve surgery)
Meng-Yao et al, 2020 [187]ChinaNeurological (stroke)
Metcalf et al, 2019 [188]United StatesCancer (radical cystectomy)
Moffet et al, 2015 [189]CanadaOrthopedic (total knee arthroplasty)
Moro Agud et al, 2016 [190]SpainPatients admitted to a hospital unit
Mousa et al, 2019 [191]United StatesSurgery (arterial revascularization with groin incision)
Moy et al, 2014 [192]United StatesPatients admitted to medical service
Nazar et al, 2016 [193]United KingdomPatients on ≥4 medicines or had changes in medicines during the hospital stay
Newnham et al, 2015 [194]AustraliaPatients discharged from the acute general medical ward
Nielsen et al, 2020 [195]DenmarkSurgery (kidney transplantation)
Nilsson et al, 2020 [196]SwedenCancer (prostate cancer surgery)
Nundy et al, 2013 [197]United StatesCardiac (heart failure)
Ong et al, 2016 [198]United StatesCardiac (heart failure)
Ostrovsky et al, 2016 [199]United States Non–condition-specific criteria (medical fee-for-service patients)
Park et al, 2017 [200]South KoreaOrthopedic (total knee replacement)
Pastora-Bernal et al, 2018 [201]SpainOrthopedic (arthroscopic subacromial decompression)
Pavic et al, 2020 [202]SwitzerlandCancer (palliative cancer care)
Pavic et al, 2020 [203]SwitzerlandCancer (palliative cancer care)
Pedone et al, 2015 [204]ItalyCardiac (heart failure)
Piau et al, 2019 [205]United StatesCancer
Piette et al, 2020 [206]United StatesPatients admitted with an illness that is associated with increased rehospitalization risk
Ponce et al, 2016 [207]United StatesSurgery (neurosurgical or orthopedic)
Prince et al, 2019 [208]United StatesCancer (hematologic malignancies)
Ramkumar et al, 2019 [209]United StatesOrthopedic (total knee arthroplasty)
Reed et al, 2020 [210]United StatesDiabetes
Reider-Demer et al, 2018 [211]United StatesNeurological (elective neurosurgery)
Requena et al, 2019 [212]SpainNeurological (stroke)
Ritchie et al, 2016 [213]United StatesMultiple conditions (heart failure and chronic obstructive pulmonary disease)
Sabir et al, 2019 [214]United KingdomNon–condition-specific criteria
Saleh et al, 2014 [215]NorwayRespiratory (chronic obstructive pulmonary disease)
Santana et al, 2017 [216]CanadaPatients admitted to medical teaching units with multiple comorbidities and complicated medication profiles
Scheper et al, 2019 [217]NetherlandsOrthopedic (joint arthroplasty)
Schneider et al, 2017 [218]United StatesNeurological (stroke)
Sinha et al, 2019 [219]United StatesPatients admitted to general medicine service
Smith et al, 2016 [220]United StatesPatients admitted to general medicine, geriatrics, or cardiology inpatient services; medically complex (≥2 comorbid conditions)
Sorknaes et al, 2011 [221]DenmarkRespiratory (chronic obstructive pulmonary disease)
Sorknaes et al, 2013 [222]DenmarkRespiratory (chronic obstructive pulmonary disease)
Sui et al, 2020 [223]ChinaCancer (surgical resection for non–small cell lung cancer)
Sun et al, 2017 [224]United StatesCancer (major abdominal cancer surgery)
Sun et al, 2017 [225]United StatesCancer (lung cancer surgery)
Tamblyn et al, 2019 [226]CanadaPatients admitted to medical and surgical hospital units
Tamblyn et al, 2018 [227]CanadaPatients admitted to medical and surgical hospital units
Timmers et al, 2019 [228]NetherlandsOrthopedic (total knee replacement)
Treskes et al, 2020 [229]NetherlandsCardiac (myocardial infarction)
van den Berg et al, 2016 [230]AustraliaNeurological (stroke)
Van der Meij et al, 2018 [231]NetherlandsSurgery (intermediate-grade abdominal surgery)
Vest et al, 2015 [232]United StatesNon–condition-specific criteria
Vesterby et al, 2017 [233]DenmarkOrthopedic (fast-track hip replacement)
Vianello et al, 2016 [234]ItalyRespiratory (chronic obstructive pulmonary disease)
Villani et al, 2014 [235]ItalyCardiac (heart failure)
Wade et al, 2012 [236]AustraliaFrail older adults with multiple chronic conditions
Wang et al, 2017 [237]ChinaRespiratory (chronic obstructive pulmonary disease)
Wang et al, 2018 [238]ChinaCancer (colorectal cancer or other digestive and urinary tumors and permanent stoma after surgery)
Wang et al, 2018 [239]ChinaOrthopedic (hip replacement surgery)
Wan et al, 2018 [240]ChinaNeurological (hypertensive ischemic stroke)
Whitehouse et al, 2020 [241]United StatesDiabetes
Wilcock et al, 2019 [242]United KingdomPatients admitted to a hospital
Wolf et al, 2016 [38]SwedenCardiac (acute coronary syndrome)
Zheng et al, 2019 [243]ChinaOrthopedic (total joint arthroplasty)
Zhou et al, 2019 [244]ChinaCancer (breast cancer surgery)
Zhou et al, 2020 [245]ChinaCancer (breast cancer surgery)
Figure 2. Year of article publication.
View this figure
Participants Targeted
Medical Conditions and Interventions Targeted

Digital health interventions were most frequently used to facilitate transitions for cardiac conditions (eg, cardiac surgery and chronic heart failure; 28/142, 19.7%) and cancer (eg, cancer surgery and cancer management; 26/142, 18.3%). Fewer digital health interventions targeted patients admitted to specific hospital units (eg, geriatric, medical, or intensive care unit; 19/142, 13.4%) and patients with multiple conditions (12/142, 8.5%), orthopedic conditions (16/142, 11.3%), neurological conditions (eg, stroke and brain tumor; 12/142, 8.5%), other surgical interventions (eg, after kidney transplantation; 11/142, 7.7%), and respiratory conditions (eg, chronic obstructive pulmonary disease management; 10/142, 7%). In addition, a small number of digital health interventions supported transitions for patients who had diabetes (3/142, 2.1%) or non–condition-specific criteria (eg, age group and medical health plan; 5/142, 3.5%).

Age Groups Targeted

In total, 15.5% (22/142) of the included interventions were conducted with samples of strictly older adults. Other interventions did not specify a targeted age range within their inclusion criteria (54/142, 38%) or had included participants aged 18 to 21 years or older (49/142, 34.5%).

Details of Digital Health Technologies

Intervention Type

Of the 142 interventions, 47 (33%) were classified into multiple categories of intervention types (N=193 intervention classifications). Of the 6 intervention-type characterizations, smartphone, tablet, or web-based interventions (91/193, 47.2%) were the most common than telemonitoring and wearables, clinical documentation system (45/193, 23.2%), clinical documentation systems (29/193, 15%), automated telephone calls or automated SMS text messaging (14/193, 7.3%), email interventions (10/193, 5.2%) or other interventions (eg, television video; 4/193, 2.1%).

Provider Roles and Functions Involved in the Intervention

As shown in Table 2, a total of 35.9% (51/142) of the interventions used multiple provider roles (n=202 provider roles identified) in the implementation of the digital health intervention, with nurses (64/202, 31.7%) and physicians (61/202, 30.2%) being the most common providers of digital health interventions. Discharge-specific personnel such as a transition coach, nurse care transition coordinator, discharge facilitator, advanced practice nurse, and systems navigator were less common (18/202, 8.9%).

Some interventions had designated a study-specific health care provider to carry out the digital health intervention activities, whereas others added the responsibility onto a provider’s existing workload. The responsibilities of providers also differed based on the type and purpose of technology and whether communication between patients and providers was initiated by patient or provider. Among some interventions with patient-initiated communication, providers had to always be available for consultation during the intervention period.

The digital health interventions were most commonly used up to 7 days after discharge (29/142, 20.4%) or between 31 and 90 days after discharge (39/142, 27.5%). It was less common for the interventions to continue for 91 days to <6 months after discharge (18/142, 12.7%) or beyond 6 months after discharge (7/142, 4.9%).

Table 2. Provider roles and examples of involvement in technology intervention used to facilitate hospital-to-home transitions (N=202).
Provider role; providers, n (%)Specific examplesExamples of provider role–technology interactions
Physician; 61 (30.2)Community physician (eg, primary care physician, ambulatory physician, and community physician), hospital physician (eg, hospitalist, resident, and most responsible physician), and specialist (eg, cardiologist, surgeon, occupational physician, geriatrician, and pulmonologist)Family physicians were alerted when patient data (eg, biometric or symptoms) fell outside predefined parameters and asked to visit or contact the patient [139]
Nurse; 64 (31.7)Specially trained nurse (trained in device use), research nurse, cancer nurse specialist, telemedicine nurse, rehabilitation nurse, nurse tutor, nurse practitioner, registered nurse, chronic obstructive pulmonary disease nurse, clinical nurse specialist, and community nurseThey reviewed all transmitted biometric and symptom data, flagged patients whose data fell outside the predefined parameters, and communicated with or assessed patients using communication technology [153,168]
Clinician; 19 (9.4)Discipline not specifiedClinicians were alerted when patient responses were outside predefined parameters, and they reviewed flagged responses [161]
Allied health; 19 (9.4)Occupational therapist, physiotherapist, social worker, and psychologistConducted telehealth consultations or sessions [37,183]
Pharmacist; 18 (8.9)Hospital or community pharmacistAccess information from other providers in the same facility or across facilities, settings or receive information from them and send information to them [214]
Navigation-specific roles; 18 (8.9)Advanced practice nurse or provider, care manager, care or program coordinator, care transition nurse, case manager, discharge planner or facilitator or discharge planning nurse, nurse navigator, post–acute care coordinator, system navigator, and transition coachProvided 24-hour consultation, which was accessible to patients through technology [175]
Other; 3 (1.5)Physician’s assistant, unit supervisor, surgical team’s physician’s assistantUsed to communicate with other providers and send and receive information [208]
Technology Functions

In terms of the technology functions that supported hospital-to-home transitions, most (116/142, 81.7%) of the technologies fell into multiple categories (ie, 57/142, 40.1%, fell into 2 categories and 59/142, 41.5%, fell into 3 categories).

Of the 317 total technology functions within the included interventions, 142 (44.8%) were related to management continuity, including following up, assessing, and monitoring patients’ status after hospital discharge, as well as facilitating referrals. Some technologies could identify values outside a predefined range during follow-up, assessment, and monitoring of patients’ status. However, others required human resources to review all data to identify abnormal values. In both cases, if values fell outside the range, a human resource (eg, provider or study personnel) had to follow-up and provide appropriate guidance and immediate treatment or the technology instructed a patient to initiate contact with a provider. Informational continuity was supported among 32.2% (102/317) of the identified technology functions, including facilitating communication (eg, between inpatient and outpatient providers or between patient and provider) and educating patients and caregivers. Relational continuity (eg, counseling and rapport building) was least supported by the technologies (73/317, 23%).

Outcomes of Interest

Of the total outcomes of interest (n=315) examined in the articles, more than half of the outcomes evaluated the effect of the intervention on patient-level factors (eg, disease knowledge, quality of life, and changes in physical or psychological functioning) and technology-user interactions (eg, use of technology, patient satisfaction with technology, and the perceived value of technology) at 28.6% (90/315) and 28.3% (89/315), respectively. Of all outcomes, 17.5% (55/315) related to health care use, examined through health care–related costs and hospital readmission rates or emergency department visits at various time points (eg, 30, 60, 90, and 180 days after discharge). The intervention effect on provider-related outcomes (eg, changes in provider workflows, provider burden, and clinical documentation accuracy), implementation-related outcomes (eg, compliance; 9/315, 2.9%), and caregiver- and family-related outcomes (eg, caregiver stress; 3/315, 1%) were less commonly examined (23/315, 7.3%). Other outcomes (eg, documentation time, economic evaluations; 46/315, 14.6%) were measured.

Lessons Learned From Digital Health Interventions

The lessons learned from the interventions pertained to challenges (eg, researcher-identified limitations or challenges of interventions) and opportunities (eg, researcher-identified strengths of interventions and recommendations); these were categorized into two broad categories: (1) technology-related and (2) research process–related (Table 3).

Table 3. Summary of the lessons learned from implementation of digital health interventions.
Challenge and descriptionExamples
Technology-related challenges

Usability issues

Participants’ physical, functional, and sensory function
  • Low vision
  • Hand tremor

Patients’ and providers’ lack of technical skills and experience
  • Forgetting log-in information or not remembering to charge the device
  • Accidentally disabling device features
  • Low technology comfort

Device-related technical issues
  • Internet connectivity issues
  • Software updates affecting function
  • Immaturity of the prototype

Fit and compatibility issues
  • Poor fit with patients’ or providers’ routine
  • Device incompatible with older devices
  • Not integrated into organization’s electronic documentation system
  • Identifying provider functions rather than their roles may enable the technology to accommodate differences among jurisdictions and changing scopes of practice

Technology content and function

Patient-facing content
  • Hypertext links were distracting and confusing
  • Language too technical
  • Offensive tone and complexity of the wording
  • Symptom-reporting questions too specific or broad caused misunderstanding

Expectations of patient-initiated provider contact
  • Not all participants were confident about the appropriate circumstances in which to contact the provider

Device notifications
  • Excessive alerts caused “alert fatigue” and resulted in less attention being paid to the alert or ignoring it altogether
Technology-related opportunities

Technology function and features

Enhancing functionality
  • Address and improve multiple components of the transition process

Accessibility, adaptations, and customization
  • Low-vision adaptations
  • Adapt for participants with low technological literacy and no social support
  • Self-directed apps
  • Use of personal devices when possible and compatibility across multiple data and operating systems
  • Provision of the device when participants do not have access to a personal device

  • Technical setup
  • Training on technology use
  • Engage caregivers in the intervention when possible

Fit with workflows, workloads, and buy-in
  • Participants, family, caregivers, and providers should inform the technology design and how technology could be integrated into the day-to-day practices of all stakeholders
  • Accounting for providers’ ethical, legal, and professional responsibilities
Research process–related challenges

Data collection

Recruitment and retention challenges
  • Lack of interest
  • High attrition

Small sample size
  • Unable to explore the relationship between participants’ profiles, participants’ adherence and compliance to intervention or conduct subgroup analyses

Sampling bias
  • Homogenous samples
  • Inclusion limited to those with technology comfort or access

Missing data
  • Impacting reliability of intervention results

Outcome measures
  • Outcome measures such as rehospitalization and survival may not be sufficiently sensitive to determine intervention impact
  • Single-blinded evaluator could introduce measurement error

Interventions across settings or institutions
  • Cross-setting coordination challenges
Research process–related opportunities

Data collection

Recruitment considerations
  • Video of 10-to-15–minute duration describing the intervention (potential benefits and utility) during recruitment to reduce apprehension
  • Consideration of low compliance rates within sample size calculations
  • Comparing the characteristics of participants with those of individuals who declined can indicate selection bias and affect the intervention’s generalizability and acceptability

  • Careful consideration of outcome measures (eg, objective or subjective) and end points

Missing data
  • Begin intervention during hospitalization
  • Schedule follow-ups during routine patient visits to minimize data lost during follow-up

Technology-Related Challenges and Opportunities

Technology-related challenges and opportunities pertained to the use of the devices.

Technology-Related Challenges

Among digital health interventions, researchers reported usability issues with the technology because of patients’ physical condition [177], patients’ or providers’ lack of technical skills and experience [159,176,177,202], and the technology not fitting into patients’ or providers’ routine and workflow [119,173]. Regarding fit with workflows, researchers emphasized that health care providers operate within regulated environments; ethical, legal, and professional considerations related to providers’ roles and care settings had to be accounted for in the design of digital health technology interventions [148,159,227]. Technical issues such as internet connectivity issues, software updates, or immaturity of the prototype [148,152,177] also decreased usability and interfered with the technology’s function (eg, restricted data transfer and alert failure) [152,202]. In addition, some researchers encountered compatibility issues with older devices and other organizations’ electronic documentation systems, which created usability issues [44,145,148,150,192,210,212].

In terms of the technical content, researchers found that some participants perceived the patient-facing content as problematic because of the technical language, tone, or complexity [152,162], as well as hypertext links that caused confusion [39,152]. Patient-initiated technology functions also presented a challenge because not all participants could use the functions or follow the instructions as intended [196]. Researchers also found it challenging to set alerts that would be appropriate for all patients because excessive alerts caused “alert fatigue” and resulted in less attention being paid to the alert or ignoring it altogether [40,44,152,157].

Technology-Related Opportunities

A few researchers emphasized that designing digital health interventions to address and improve multiple components of the transition process may enhance functionality [119,145]. In addition, they indicated that technology accessibility, adaptations, or customization could accommodate individual preferences and increase applicability to different populations [39,140,205,227]. Researchers indicated that increasing accessibility could start with providing the technology to participants without a personal device to reduce disparities of access based on technology ownership [150]. Researchers suggested using participants’ devices to enhance usability when possible, which may require compatibility across multiple data and operating systems [122,167,212]. In addition, technical setup and training on using the technology and engaging caregivers in the intervention could support the usability and intervention quality, safety, and adherence [112,135,157]. Moreover, building self-directed functions might help overcome logistical barriers associated with scheduled interventions [136]. This finding extends to timely feedback because researchers found that participants wanted to be notified when providers had reviewed their responses [150].

To address the technology’s fit with workflows, workloads, and buy-in, some researchers believed that participants, family, caregivers, and providers should be engaged in helping to design the intervention [136,148,228]. Researchers found that interventions that placed high accountability and responsibility on health care providers and added additional work to their workload resulted in provider-related usability issues because providers “struggled to find time in their day” to carry out intervention activities [40,150,195]. Researchers noted that identifying functions rather than provider roles may enable the technology to accommodate differences among jurisdictions (eg, country and institution) and changing scopes of practice over time [227]. Alternatively, if human resources are limited, interventions using automated telephone calls or central monitoring centers for multiple institutions could be considered to reduce the number of personnel and time required for monitoring [188]. Thus, understanding how technology could be integrated into the day-to-day practices of all stakeholders was an essential task for technology developers, along with helping providers envision ways to implement the technology in practice [119,181].

Research Process–Related Challenges and Opportunities

Challenges and opportunities within the reported research processes pertained to the recruitment process, data collection, and study and intervention designs.

Research Process–Related Challenges

Recruitment challenges and high attrition were commonly reported within the studies [135,246]. As several interventions had a small sample size, researchers acknowledged limitations, including being unable to explore the relationship between participants’ profiles and adherence and compliance information or conduct subgroup analyses [112,135,157,205]. Researchers reported that sampling bias could have had an impact on the generalizability of their results because the samples were small [115,141,165] and homogenous (ie, primarily White) [150] and could have been exacerbated because inclusion was limited to participants with internet-enabled devices [201]. Missing data was another concern reported by researchers that may have affected the reliability of the intervention results [158].

Beyond data collection, researchers reported that interventions conducted at a single site may have reduced generalizability to other settings [160,181,218,226,241]. The study by DeVito Dabbs et al [140] indicated that outcome measures such as rehospitalization and survival may not be sufficiently sensitive to identify the impact of a technology intervention.

Researchers found that effectively integrating the technology in clinical environments would likely require early engagement with patients and providers, support from senior leadership, integration within existing electronic systems [119,144,148,166], and testing of technologies in real-world settings to identify implementation barriers [140]. Finally, researchers of a digital health technology intervention that operated across settings or institutions reported challenges with coordination among providers in hospital, primary care, and community settings [148].

Research Process–Related Opportunities

Several researchers recommended more extensive and diverse participant samples in future digital health interventions [150,171,173,247] and consideration of low compliance rates within sample size calculations [173]. They believed that providing participants with an explanation of the potential benefits and utility of the technology may also enhance study participation [173]. In addition, comparing the characteristics of participants with those of individuals who declined participation gave researchers insight into selection bias and the intervention’s generalizability and acceptability [151,169,231,237].

Regarding outcomes of interest, researchers advised carefully considering which outcome measures (eg, objective or subjective) [173,224] and end points to use [186,193]; multicenter studies with longer follow-up time (ie, >30 days after discharge) might be required to observe the intervention’s effect on patient-clinician relationships [160,181]. Opportunities identified by researchers to improve data include analyzing technology log data for objective data on patients’ and providers’ use of technology [186,193], beginning the intervention within the hospital setting, and incorporating the follow-ups into routine patient visits to potentially minimize data lost during follow-up [141,148].


This rapid review provides an overview of digital health interventions supporting hospital-to-home transitions and describes how the technologies have been used to support the roles and functions of health care providers in supporting these transitions. Consistent with the aim of a rapid review approach, we have compiled a set of recommendations (Table 4) to guide the design of new and existing digital health interventions such as Digital Bridge that support hospital-to-home transitions based upon the reviewed literature. Our review extends and complements the existing literature [41,42,248] by highlighting transition-specific considerations within the design and implementation of future digital health interventions that better support provider roles and functions during transitions.

Table 4. Recommendations to guide the design and implementation of digital health interventions to facilitate hospital-to-home transitions.
Recommendation 1: align the design and delivery of digital health interventions to provider functions
  • As roles and functions can differ based on several factors (eg, the organizations, jurisdiction, and care settings), technology functions should consider the roles and functions relevant to their target setting; alternatively, to increase generalizability, technology may need to support specific provider functions (ie, provider responsibilities) rather than outlining specific roles (ie, provider titles)
  • Address multiple functions within transitional care, including functions supporting informational, management, and relational continuity of care
  • Integration of technology with multiple organizations and across care settings
  • Added provider functions with technology use should be minimal (eg, automated and self-directed functions could be integrated into interventions to reduce provider functions)
  • Share functions related to technology use with patients and caregivers when possible
  • Begin before or immediately after hospital admission and extend care into the community
Recommendation 2: design for, and test with, older adults
  • To ensure that technology functions effectively meet the transitional care needs of older adults, digital health interventions should be designed for, and tested with, older adults
  • Consider strategies to recruit and retain older adults with poor health
  • Consider how technology functions may affect inequities
  • Include caregivers, when possible, in digital health interventions because they play valuable roles in hospital-to-home transitions
Recommendation 3: examine multilevel outcomes
  • Examine reasons for declining and dropping out of interventions
  • Examine multilevel outcomes
  • Provider-level outcomes may give insight into whether technology functions are perceived to support provider functions effectively
  • Evaluate specific technology functions
Recommendation 1: Align the Design and Delivery of Digital Health Interventions With Provider Functions

This review demonstrates that many existing technologies that support hospital-to-home transitions encounter implementation-related barriers. The health care system is complex, and the discharge process is often “busy, rushed and emotional” [249]. During hospital-to-home transitions, patients move from one setting to another and provider functions and responsibilities become unclear because communication often fails to cross boundaries [250]. Thus, a critical lesson from this review is that digital health interventions should emphasize the provider functions that the technology supports rather than focusing on how professional groups can use solutions because roles and functions can differ by organization and care setting.

We have highlighted that many providers involved in transitions tend to have overlapping functions. We have outlined specific provider functions that could be built into the design of digital health interventions to support transitional care workflows and potentially reduce provider burden. These functions may address the factors presently limiting uptake of digital health interventions, including poor fit with providers’ functions and provider perceptions of low degree of usefulness [41,42,248]. To meaningfully support hospital-to-home transitions, digital health interventions may need to address multiple functions involved in patient care beyond primarily supporting functions related to management continuity (eg, monitoring) and informational continuity. On the basis of the findings from this review, technology functions related to relational continuity warrant further exploration. These are the components that are appropriate for technology to address and support and the ones that rely on the interface between people and technology.

Moreover, technologies should be designed to minimize the burden on providers and be designed in such a way that they can support provider functions. Although technologies demonstrate their ability to support specific provider functions such as remote monitoring and patient education, they add functions and place high levels of accountability on single providers. For instance, remote monitoring technologies could yield large quantities of data that providers then become responsible for sorting through and acting on, adding another function to their workload [120,153]. Integration of such technologies in clinical practice could be unfeasible because the added provider functions are among the prominent barriers to the uptake of technologies [41].

Perceived usefulness may be improved by highlighting how the purpose and function of the technology fit with the functions of providers during hospital-to-home transitions and whether it could result in time savings and the workload reduction of providers and by outlining the responsibilities of providers in the delivery of digital health interventions [140]. Furthermore, as technologies integrate more advanced and automated functions, the burden on providers may be reduced. For instance, automated reminders may reduce demands on providers [34]. However, advanced technologies may not be suitable for all patients and these individuals may require training to recognize red flags and when to re-engage with providers [152]. Sharing responsibility with, and facilitating more active involvement of, patients and caregivers (when appropriate) or adding trained volunteers may be another way to reduce the added responsibility faced by health care providers [251].

Recommendation 2: Design for, and Test Digital Health Interventions Specifically With, Older Adults

Older adults have unique transitional care needs that the providers strive to meet through their functions. Provider functions to achieve relational and informational continuity of care have been deemed necessary to achieve high-quality hospital-to-home transitions for older adults [22,252]. However, we identified these functions to be a gap in the existing digital health interventions supporting hospital-to-home transitions because these functions were least supported by technology. We believe that these should be integrated within technology functions of future digital health interventions.

Of note, this review revealed that digital health interventions were rarely designed to meet the unique needs of older adults or exclusively tested with older adults. Thus, we contend that future technology functions should be designed to meet these specific transitional care needs while also accounting for design considerations related to older adults’ complex needs, including physical, cognitive, and sensory needs [253-255]. Moreover, new strategies may be needed to recruit and retain older adults with poor health status. Using human-centered design principles, including co-designing and testing with clinicians and older adults with complex care needs, may enhance the use and effectiveness of interventions [41,248] and could reveal how better to integrate relational management into the technology functions. Furthermore, critical investigations of how the functions of existing digital health interventions may have contributed to the exacerbation of inequities are necessary to highlight new insights and guidance for functions of future interventions to eliminate such disparities [255,256].

Recommendation 3: Examine Multilevel Outcomes

We recommend that those leading digital health interventions examine outcomes of interest at multiple levels, including the patient, provider, organization, and system levels. Most transitional interventions examined the impact of digital health interventions on patient-level outcomes. However, not all studies had examined why participants declined or dropped out of digital health interventions, which would have provided valuable insights for future work. Provider-, organization-, and system-level outcomes were less common but are essential to consider. Although patient-level outcomes are helpful, costs and benefits need to be assessed for health care organizations and health systems, including economic feasibility and quality measures [257]. In particular, exploring patient-level outcomes can provide insight into whether the technology functions effectively support the provider functions.

Moreover, evaluating specific technology functions may provide insights into which ones may need to be refined. Researchers may also further explore the feasibility and benefits of transition-specific roles to support digitally enabled transitions because these studies were limited. In addition, reporting research-level outcomes, including insights and reflections from the research teams, may contribute valuable knowledge that could guide future interventions.


Several factors limit this review. First, the rapid review methodology (eg, single-reviewer title and abstract screening and limited number of databases searched) may have led to missing relevant articles. Title and abstract screening were initiated after a minimum interrater reliability among screeners of κ=0.80 (ie, sufficient interrater reliability) was achieved to reduce the risk of missing relevant articles [258]. Second, there is a lack of standardized terminology and definitions for hospital-to-home transitions, provider roles and functions, transitional interventions, and digital health technologies. Thus, our inclusion criteria were difficult to apply and we had to create additional parameters to judge whether the studies related to these areas. For example, to be considered a hospital-to-home transition intervention, the intervention had to begin (ie, recruitment) at the hospital and extend to the community. It is also possible that some articles that failed to provide a detailed methodology could have been mistakenly excluded. However, this review was not intended to map the relevant literature entirely but rather to provide an overview of the landscape. Third, although we planned to conduct a quality appraisal using the Mixed Methods Appraisal Tool [259,260], we decided against a formal quality appraisal for two reasons: (1) the studies did not report sufficient details of their intervention design and methods for the team to appraise their quality confidently and accurately (eg, Is randomization appropriately performed? and Are outcome assessors blinded to the intervention provided?) and (2) this review intended to focus on critical lessons learned from the processes involved in designing, delivering, and evaluating the interventions rather than the interventions’ effectiveness (eg, outcomes); thus, an appraisal was not critical to meet these objectives. We recommend that future digital health interventions report comprehensive details of their methods to enable future reviews to critically appraise them. Fourth, the inclusion criteria were modified to capture the most relevant literature and data during the review process. However, this led to deviations from the protocol (eg, excluding telephone-based interventions). Fifth, the purpose of phase 1 was to characterize typical roles and critical functions involved in transitions to create a general understanding of the context rather than to create an exhaustive list of all roles. However, we acknowledge that several roles, including the roles and functions of specialized health professionals, may not have been reflected in the results. In addition, roles and functions may also differ by factors such as the institution, country or region, and clinical setting. Thus, technology designers should consult with their intended users to ensure that the technology aligns with their roles and functions. Sixth, each article was reported as a single intervention because we could not link articles that reported a single intervention’s outcomes within multiple articles. Finally, the findings are not limited to older adults because we included any study that included at least one older adult. Nonetheless, this review provides valuable information to guide the design and implementation of existing and new digital health interventions such as the Digital Bridge.


In conclusion, this review provides an overview of the landscape of digital health interventions that support hospital-to-home transitions and identifies recommendations for future studies based on the lessons learned. The findings from this review will serve as a valuable guide for the design and implementation of Digital Bridge and other digital health interventions to support hospital-to-home transitions.


The authors would like to thank the authors of the included work for their valuable contributions to transitions of care. This study was funded by the Canadian Institute for Health Research through a Team Grant in Transitions in Care (FRN 165733).

Conflicts of Interest

None declared.

Multimedia Appendix 1

Search strategies.

DOCX File , 31 KB

Multimedia Appendix 2

Phase 2 inclusion criteria.

DOCX File , 19 KB

  1. Werner NE, Tong M, Borkenhagen A, Holden RJ. Performance-shaping factors affecting older adults' hospital-to-home transition success: a systems approach. Gerontologist 2019 Mar 14;59(2):303-314 [FREE Full text] [CrossRef] [Medline]
  2. Neiterman E, Wodchis WP, Bourgeault IL. Experiences of older adults in transition from hospital to community. Can J Aging 2015 Mar;34(1):90-99. [CrossRef] [Medline]
  3. Naylor MD. Transitional care for older adults: a cost-effective model. LDI Issue Brief 2004;9(6):1-4. [Medline]
  4. Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N Engl J Med 2013 Jan 10;368(2):100-102 [FREE Full text] [CrossRef] [Medline]
  5. Foust JB, Naylor MD, Bixby MB, Ratcliffe SJ. Medication problems occurring at hospital discharge among older adults with heart failure. Res Gerontol Nurs 2012 Jan;5(1):25-33. [CrossRef] [Medline]
  6. Andreasen J, Lund H, Aadahl M, Sørensen EE. The experience of daily life of acutely admitted frail elderly patients one week after discharge from the hospital. Int J Qual Stud Health Well-being 2015 Jun 1;10:27370 [FREE Full text] [CrossRef] [Medline]
  7. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009 Apr 02;360(14):1418-1428. [CrossRef] [Medline]
  8. Mesquita ET, Cruz LN, Mariano BM, Jorge AJ. Post-hospital syndrome: a new challenge in cardiovascular practice. Arq Bras Cardiol 2015 Nov;105(5):540-544 [FREE Full text] [CrossRef] [Medline]
  9. van Seben R, Reichardt LA, Essink DR, van Munster BC, Bosch JA, Buurman BM. "I feel worn out, as if i neglected myself": older patients' perspectives on post-hospital symptoms after acute hospitalization. Gerontologist 2019 Mar 14;59(2):315-326. [CrossRef] [Medline]
  10. Hestevik CH, Molin M, Debesay J, Bergland A, Bye A. Older persons' experiences of adapting to daily life at home after hospital discharge: a qualitative metasummary. BMC Health Serv Res 2019 Apr 11;19(1):224 [FREE Full text] [CrossRef] [Medline]
  11. Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, et al. Adverse events among medical patients after discharge from hospital. CMAJ 2004 Feb 03;170(3):345-349 [FREE Full text] [Medline]
  12. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003 Feb 04;138(3):161-167. [CrossRef] [Medline]
  13. Finn KM, Heffner R, Chang Y, Bazari H, Hunt D, Pickell K, et al. Improving the discharge process by embedding a discharge facilitator in a resident team. J Hosp Med 2011 Nov;6(9):494-500. [CrossRef] [Medline]
  14. Cutler DM. The incidence of adverse medical outcomes under prospective payment. Econometrica 1995 Jan;63(1):29-50. [CrossRef]
  15. Kosecoff J, Kahn KL, Rogers WH, Reinisch EJ, Sherwood MJ, Rubenstein LV, et al. Prospective payment system and impairment at discharge. The 'quicker-and-sicker' story revisited. JAMA 1990 Oct 17;264(15):1980-1983. [Medline]
  16. Abrashkin KA, Cho HJ, Torgalkar S, Markoff B. Improving transitions of care from hospital to home: what works? Mt Sinai J Med 2012;79(5):535-544. [CrossRef] [Medline]
  17. Rennke S, Ranji SR. Transitional care strategies from hospital to home: a review for the neurohospitalist. Neurohospitalist 2015 Jan;5(1):35-42 [FREE Full text] [CrossRef] [Medline]
  18. Gulliford M, Naithani S, Morgan M. What is 'continuity of care'? J Health Serv Res Policy 2006 Oct;11(4):248-250. [CrossRef] [Medline]
  19. Goldfield NI, McCullough EC, Hughes JS, Tang AM, Eastman B, Rawlins LK, et al. Identifying potentially preventable readmissions. Health Care Financ Rev 2008;30(1):75-91 [FREE Full text] [Medline]
  20. Mansukhani RP, Bridgeman MB, Candelario D, Eckert LJ. Exploring transitional care: evidence-based strategies for improving provider communication and reducing readmissions. P T 2015 Oct;40(10):690-694 [FREE Full text] [Medline]
  21. Norlyk A, Deleuran CL, Martinsen B. Struggles with infrastructures of information concerning hospital-to-home transitions. Br J Community Nurs 2020 Jan 02;25(1):10-15 [FREE Full text] [CrossRef] [Medline]
  22. Allen J, Hutchinson AM, Brown R, Livingston PM. User experience and care for older people transitioning from hospital to home: patients' and carers' perspectives. Health Expect 2018 Apr;21(2):518-527 [FREE Full text] [CrossRef] [Medline]
  23. Coleman EA, Boult C, American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc 2003 Apr;51(4):556-557. [CrossRef] [Medline]
  24. Naylor MD. Transitional care of older adults. Annu Rev Nurs Res 2002;20:127-147. [Medline]
  25. Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc 2004 Nov;52(11):1817-1825. [CrossRef] [Medline]
  26. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006 Sep 25;166(17):1822-1828. [CrossRef] [Medline]
  27. Parry C, Min SJ, Chugh A, Chalmers S, Coleman EA. Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Serv Q 2009;28(2-3):84-99. [CrossRef] [Medline]
  28. Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med 2011 Jul 25;171(14):1232-1237. [CrossRef] [Medline]
  29. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA 1999 Feb 17;281(7):613-620. [CrossRef] [Medline]
  30. Wilkinson ST, Aroop P, Richard JC. Impacting readmission rates and patient satisfaction: results of a discharge pharmacist pilot program. Hosp Pharm 2011 Nov 01;46(11):876-883. [CrossRef]
  31. Hansen LO, Greenwald JL, Budnitz T, Howell E, Halasyamani L, Maynard G, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med 2013 Aug;8(8):421-427. [CrossRef] [Medline]
  32. Kalu ME, Maximos M, Sengiad S, Dal Bello-Haas V. The role of rehabilitation professionals in care transitions for older adults: a scoping review. Phys Occup Ther Geriatr 2019 Jun 20;37(3):123-150. [CrossRef]
  33. Dohan D, Schrag D. Using navigators to improve care of underserved patients: current practices and approaches. Cancer 2005 Aug 15;104(4):848-855 [FREE Full text] [CrossRef] [Medline]
  34. Austin LS, Landis CO, Hanger Jr KH. Extending the continuum of care in congestive heart failure: an interactive technology self-management solution. J Nurs Adm 2012 Sep;42(9):442-446. [CrossRef] [Medline]
  35. Bouwsma EV, Bosmans JE, van Dongen JM, Brölmann HA, Anema JR, Huirne JA. Cost-effectiveness of an Internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: economic evaluation alongside a stepped-wedge cluster-randomised trial. BMJ Open 2018 Jan 21;8(1):e017782 [FREE Full text] [CrossRef] [Medline]
  36. Lavu H, McCall NS, Winter JM, Burkhart RA, Pucci M, Leiby BE, et al. Enhancing patient outcomes while containing costs after complex abdominal operation: a randomized controlled trial of the whipple accelerated recovery pathway. J Am Coll Surg 2019 Apr;228(4):415-424 [FREE Full text] [CrossRef] [Medline]
  37. Lafaro KJ, Raz DJ, Kim JY, Hite S, Ruel N, Varatkar G, et al. Pilot study of a telehealth perioperative physical activity intervention for older adults with cancer and their caregivers. Support Care Cancer 2020 Aug;28(8):3867-3876 [FREE Full text] [CrossRef] [Medline]
  38. Wolf A, Fors A, Ulin K, Thorn J, Swedberg K, Ekman I. An eHealth diary and symptom-tracking tool combined with person-centered care for improving self-efficacy after a diagnosis of acute coronary syndrome: a substudy of a randomized controlled trial. J Med Internet Res 2016 Feb 23;18(2):e40 [FREE Full text] [CrossRef] [Medline]
  39. Choi J, Jacelon CS, Kalmakis KA. Web-based, pictograph-formatted discharge instructions for low-literacy older adults after hip replacement surgery: findings of end-user evaluation of the website. Rehabil Nurs 2017;42(5):254-261. [CrossRef] [Medline]
  40. Gurwitz JH, Field TS, Ogarek J, Tjia J, Cutrona SL, Harrold LR, et al. An electronic health record-based intervention to increase follow-up office visits and decrease rehospitalization in older adults. J Am Geriatr Soc 2014 May;62(5):865-871 [FREE Full text] [CrossRef] [Medline]
  41. Whitelaw S, Pellegrini DM, Mamas MA, Cowie M, Van Spall HG. Barriers and facilitators of the uptake of digital health technology in cardiovascular care: a systematic scoping review. Eur Heart J Digit Health 2021 Feb 4;2(1):62-74 [FREE Full text] [CrossRef] [Medline]
  42. Palacholla RS, Fischer N, Coleman A, Agboola S, Kirley K, Felsted J, et al. Provider- and patient-related barriers to and facilitators of digital health technology adoption for hypertension management: scoping review. JMIR Cardio 2019 Mar 26;3(1):e11951 [FREE Full text] [CrossRef] [Medline]
  43. Singh H, Armas A, Law S, Tang T, Steele Gray C, Cunningham HV, et al. How digital health solutions align with the roles and functions that support hospital to home transitions for older adults: a rapid review study protocol. BMJ Open 2021 Feb 25;11(2):e045596 [FREE Full text] [CrossRef] [Medline]
  44. El-Kareh R, Roy C, Williams DH, Poon EG. Impact of automated alerts on follow-up of post-discharge microbiology results: a cluster randomized controlled trial. J Gen Intern Med 2012 Oct;27(10):1243-1250 [FREE Full text] [CrossRef] [Medline]
  45. Steele Gray C, Tang T, Armas A, Backo-Shannon M, Harvey S, Kuluski K, et al. Building a digital bridge to support patient-centered care transitions from hospital to home for older adults with complex care needs: protocol for a co-design, implementation, and evaluation study. JMIR Res Protoc 2020 Nov 25;9(11):e20220. [CrossRef] [Medline]
  46. Tricco AC, Langlois EV, Straus SE. Rapid reviews to strengthen health policy and systems: a practical guide. World Health Organization. 2017.   URL: [accessed 2022-01-06]
  47. Bryant SL. The information needs and information seeking behaviour of family doctors. Health Info Libr J 2004 Jun;21(2):84-93 [FREE Full text] [CrossRef] [Medline]
  48. Linda NS, Phetlhu DR, Klopper HC. Significance of literature when constructing a theory: a selective literature review. Afr J Phys Health Educ Recreat Dance 2014 Oct;2(Supplement 1):502-512.
  49. MEDLINE: overview. National Library of Medicine. 2021.   URL: [accessed 2022-03-15]
  50. Haddaway NR, Collins AM, Coughlin D, Kirk S. The role of Google Scholar in evidence reviews and its applicability to grey literature searching. PLoS One 2015 Sep 17;10(9):e0138237 [FREE Full text] [CrossRef] [Medline]
  51. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006 Jan;3(2):77-101. [CrossRef]
  52. Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003 Nov 22;327(7425):1219-1221 [FREE Full text] [CrossRef] [Medline]
  53. Rethlefsen ML, Kirtley S, Waffenschmidt S, Ayala AP, Moher D, Page MJ, PRISMA-S Group. PRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews. Syst Rev 2021 Jan 26;10(1):39 [FREE Full text] [CrossRef] [Medline]
  54. World Bank Country and Lending Groups. The World Bank. 2020.   URL: https:/​/datahelpdesk.​​knowledgebase/​articles/​906519-world-bank-country-and-lending-groups [accessed 2020-08-10]
  55. Iyawa GE, Herselman M, Botha A. Digital health innovation ecosystems: from systematic literature review to conceptual framework. Procedia Comput Sci 2016;100:244-252. [CrossRef]
  56. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ 2014 Mar 07;348:g1687. [CrossRef] [Medline]
  57. Acuña Mora M, Moons P, Sparud-Lundin C, Bratt EL, Goossens E. Assessing the level of evidence on transfer and transition in young people with chronic conditions: protocol of a scoping review. Syst Rev 2016 Sep 29;5(1):166 [FREE Full text] [CrossRef] [Medline]
  58. Manderson B, McMurray J, Piraino E, Stolee P. Navigation roles support chronically ill older adults through healthcare transitions: a systematic review of the literature. Health Soc Care Community 2012 Mar;20(2):113-127. [CrossRef] [Medline]
  59. Farrell TW, Tomoaia-Cotisel A, Scammon DL, Brunisholz K, Kim J, Day J, et al. Impact of an integrated transition management program in primary care on hospital readmissions. J Healthc Qual 2015;37(1):81-92. [CrossRef] [Medline]
  60. Eaton CK. Social workers, nurses, or both: who is primarily responsible for hospital discharge planning with older adults? Soc Work Health Care 2018;57(10):851-863. [CrossRef] [Medline]
  61. Lim WK, Lambert SF, Gray LC. Effectiveness of case management and post-acute services in older people after hospital discharge. Med J Aust 2003 Mar 17;178(6):262-266. [CrossRef] [Medline]
  62. Balaban RB, Galbraith AA, Burns ME, Vialle-Valentin CE, Larochelle MR, Ross-Degnan D. A patient navigator intervention to reduce hospital readmissions among high-risk safety-net patients: a randomized controlled trial. J Gen Intern Med 2015 Jul;30(7):907-915 [FREE Full text] [CrossRef] [Medline]
  63. Campagna V, Nelson SA, Krsnak J. Improving care transitions to drive patient outcomes: the triple aim meets the four pillars. Prof Case Manag 2019;24(6):297-305. [CrossRef] [Medline]
  64. Dedhia P, Kravet S, Bulger J, Hinson T, Sridharan A, Kolodner K, et al. A quality improvement intervention to facilitate the transition of older adults from three hospitals back to their homes. J Am Geriatr Soc 2009 Sep;57(9):1540-1546. [CrossRef] [Medline]
  65. American College of Clinical Pharmacy, Hume AL, Kirwin J, Bieber HL, Couchenour RL, Hall DL, et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy 2012 Nov;32(11):e326-e337. [CrossRef] [Medline]
  66. Rottman-Sagebiel R, Cupples N, Wang CP, Cope S, Pastewait S, Braden H, et al. A pharmacist-led transitional care program to reduce hospital readmissions in older adults. Fed Pract 2018 Dec;35(12):42-50 [FREE Full text] [Medline]
  67. Dukkers van Emden DM, Ros WJ, Berns MP. Transition of care: an evaluation of the role of the discharge liaison nurse in The Netherlands. J Adv Nurs 1999 Nov;30(5):1186-1194. [CrossRef] [Medline]
  68. Farkas J, Kadivec S, Kosnik M, Lainscak M. Effectiveness of discharge-coordinator intervention in patients with chronic obstructive pulmonary disease: study protocol of a randomized controlled clinical trial. Respir Med 2011 Oct;105 Suppl 1:S26-S30 [FREE Full text] [CrossRef] [Medline]
  69. Fabbre VD, Buffington AS, Altfeld SJ, Shier GE, Golden RL. Social work and transitions of care: observations from an intervention for older adults. J Gerontol Soc Work 2011;54(6):615-626. [CrossRef] [Medline]
  70. Dilworth-Anderson P, Hilliard TS, Williams S, Palmer MH. A contextual conceptualization on transitions of care for older persons: shaping the direction of care. Annu Rev Gerontol Geriatr 2011 Nov 01;31(1):1-14. [CrossRef]
  71. Gibson AF, Lee C, Crabb S. ‘Take ownership of your condition’: Australian women’s health and risk talk in relation to their experiences of breast cancer. Health Risk Soc 2015 Apr 11;17(2):132-148. [CrossRef]
  72. Yatim F, Cristofalo P, Ferrua M, Girault A, Lacaze M, Di Palma M, et al. Analysis of nurse navigators' activities for hospital discharge coordination: a mixed method study for the case of cancer patients. Support Care Cancer 2017 Mar;25(3):863-868 [FREE Full text] [CrossRef] [Medline]
  73. Kowalkowski M, Chou SH, McWilliams A, Lashley C, Murphy S, Rossman W, Atrium Health ACORN Investigators. Structured, proactive care coordination versus usual care for Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS): a pragmatic, randomized controlled trial. Trials 2019 Nov 29;20(1):660 [FREE Full text] [CrossRef] [Medline]
  74. Meisinger C, Stollenwerk B, Kirchberger I, Seidl H, Wende R, Kuch B, et al. Effects of a nurse-based case management compared to usual care among aged patients with myocardial infarction: results from the randomized controlled KORINNA study. BMC Geriatr 2013 Oct 29;13:115 [FREE Full text] [CrossRef] [Medline]
  75. Occelli P, Touzet S, Rabilloud M, Ganne C, Poupon Bourdy S, Galamand B, et al. Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial. BMC Geriatr 2016 Mar 03;16:57 [FREE Full text] [CrossRef] [Medline]
  76. Foret Giddens J, Tanner E, Frey K, Reider L, Boult C. Expanding the gerontological nursing role in Guided Care. Geriatr Nurs 2009;30(5):358-364. [CrossRef] [Medline]
  77. Parry C, Coleman EA. Active roles for older adults in navigating care transitions: lessons learned from the care transitions intervention. Open Longev Sci 2010;4:43-50. [CrossRef]
  78. Franklin MM, McCoy MA. The transition of care from hospital to home for patients with hypertension. Nurse Pract 2017 Feb 12;42(2):12-18. [CrossRef] [Medline]
  79. Missel M, Schønau MN, Pedersen JH, Pedersen PU. Transition from hospital to daily life: a pilot study. Rehabil Nurs 2015;40(1):20-29. [CrossRef] [Medline]
  80. Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med 2006 Mar 13;166(5):565-571. [CrossRef] [Medline]
  81. Young AM, Mudge AM, Banks MD, Rogers L, Demedio K, Isenring E. Improving nutritional discharge planning and follow up in older medical inpatients: Hospital to Home Outreach for Malnourished Elders. Nutr Diet 2018 Jul;75(3):283-290. [CrossRef] [Medline]
  82. Leland NE, Roberts P, De Souza R, Hwa Chang S, Shah K, Robinson M. Care transition processes to achieve a successful community discharge after postacute care: a scoping review. Am J Occup Ther 2019;73(1):7301205140p1-7301205140p9. [CrossRef] [Medline]
  83. Aboumatar H, Naqibuddin M, Chung S, Adebowale H, Bone L, Brown T, BREATHE Study Patient Family Partners Group. Better Respiratory Education and Treatment Help Empower (BREATHE) study: methodology and baseline characteristics of a randomized controlled trial testing a transitional care program to improve patient-centered care delivery among chronic obstructive pulmonary disease patients. Contemp Clin Trials 2017 Nov;62:159-167. [CrossRef] [Medline]
  84. Scott LB, Gravely S, Sexton TR, Brzostek S, Brown DL. Examining the effect of a patient navigation intervention on outpatient cardiac rehabilitation awareness and enrollment. J Cardiopulm Rehabil Prev 2013;33(5):281-291 [FREE Full text] [CrossRef] [Medline]
  85. Gibson MJ, Kelly KA, Kaplan AK. Family caregiving and transitional care: a critical review. Family Caregiver Alliance. 2012 Oct.   URL: [accessed 2022-01-06]
  86. Kwok T, Lum CM, Chan HS, Ma HM, Lee D, Woo J. A randomized, controlled trial of an intensive community nurse-supported discharge program in preventing hospital readmissions of older patients with chronic lung disease. J Am Geriatr Soc 2004 Aug;52(8):1240-1246. [CrossRef] [Medline]
  87. Falvey JR, Burke RE, Malone D, Ridgeway KJ, McManus BM, Stevens-Lapsley JE. Role of physical therapists in reducing hospital readmissions: optimizing outcomes for older adults during care transitions from hospital to community. Phys Ther 2016 Aug;96(8):1125-1134 [FREE Full text] [CrossRef] [Medline]
  88. Acher AW, Campbell-Flohr SA, Brenny-Fitzpatrick M, Leahy-Gross KM, Fernandes-Taylor S, Fisher AV, et al. Improving patient-centered transitional care after complex abdominal surgery. J Am Coll Surg 2017 Aug;225(2):259-265 [FREE Full text] [CrossRef] [Medline]
  89. Bryant-Lukosius D, Carter N, Reid K, Donald F, Martin-Misener R, Kilpatrick K, et al. The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review. J Eval Clin Pract 2015 Oct;21(5):763-781. [CrossRef] [Medline]
  90. Balaban RB, Williams MV. Improving care transitions: hospitalists partnering with primary care. J Hosp Med 2010 Sep;5(7):375-377. [CrossRef] [Medline]
  91. Balaban RB, Zhang F, Vialle-Valentin CE, Galbraith AA, Burns ME, Larochelle MR, et al. Impact of a patient navigator program on hospital-based and outpatient utilization over 180 days in a safety-net health system. J Gen Intern Med 2017 Sep;32(9):981-989 [FREE Full text] [CrossRef] [Medline]
  92. Gordils-Perez J, Schneider SM, Gabel M, Trotter KJ. Oncology nurse navigation: development and implementation of a program at a comprehensive cancer center

. Clin J Oncol Nurs 2017 Oct 01;21(5):581-588. [CrossRef] [Medline]
  93. Parker VA, Clark JA, Leyson J, Calhoun E, Carroll JK, Freund KM, et al. Patient navigation: development of a protocol for describing what navigators do. Health Serv Res 2010 Apr;45(2):514-531 [FREE Full text] [CrossRef] [Medline]
  94. Dillworth J, Dickson VV, Mueller A, Shuluk J, Yoon HW, Capezuti E. Nurses' perspectives: hospitalized older patients and end-of-life decision-making. Nurs Crit Care 2016 Mar;21(2):e1-11. [CrossRef] [Medline]
  95. Peters P, Fleuren M, Wijkel D. The quality of the discharge planning process: the effect of a liaison nurse. Int J Qual Health Care 1997 Aug;9(4):283-287. [CrossRef] [Medline]
  96. Plant N, Mallitt KA, Kelly PJ, Usherwood T, Gillespie J, Boyages S, et al. Implementation and effectiveness of 'care navigation', coordinated management for people with complex chronic illness: rationale and methods of a randomised controlled trial. BMC Health Serv Res 2013 May 03;13:164 [FREE Full text] [CrossRef] [Medline]
  97. Coleman EA, Chugh A, Williams MV, Grigsby J, Glasheen JJ, McKenzie M, et al. Understanding and execution of discharge instructions. Am J Med Qual 2013;28(5):383-391. [CrossRef] [Medline]
  98. Naylor MD, Bowles KH, Brooten D. Patient problems and advanced practice nurse interventions during transitional care. Public Health Nurs 2000;17(2):94-102. [CrossRef] [Medline]
  99. Boult C, Wieland GD. Comprehensive primary care for older patients with multiple chronic conditions: "Nobody rushes you through". JAMA 2010 Nov 03;304(17):1936-1943. [CrossRef] [Medline]
  100. Damery S, Flanagan S, Combes G. Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews. BMJ Open 2016 Nov 21;6(11):e011952 [FREE Full text] [CrossRef] [Medline]
  101. Mackavey C. Advanced practice nurse transitional care model promotes healing in wound care. Care Manag J 2016 Sep 01;17(3):140-149. [CrossRef] [Medline]
  102. McMurray A, Cooper H. The nurse navigator: an evolving model of care. Collegian 2017 Apr;24(2):205-212 [FREE Full text] [CrossRef]
  103. Naylor MD, Bowles KH, McCauley KM, Maccoy MC, Maislin G, Pauly MV, et al. High-value transitional care: translation of research into practice. J Eval Clin Pract 2013 Oct;19(5):727-733. [CrossRef] [Medline]
  104. Meade CD, Wells KJ, Arevalo M, Calcano ER, Rivera M, Sarmiento Y, et al. Lay navigator model for impacting cancer health disparities. J Cancer Educ 2014 Sep;29(3):449-457 [FREE Full text] [CrossRef] [Medline]
  105. Prieto-Centurion V, Basu S, Bracken N, Calhoun E, Dickens C, DiDomenico RJ, et al. Design of the patient navigator to Reduce Readmissions (PArTNER) study: a pragmatic clinical effectiveness trial. Contemp Clin Trials Commun 2019 Sep;15:100420 [FREE Full text] [CrossRef] [Medline]
  106. Jeffs L, Kuluski K, Law M, Saragosa M, Espin S, Ferris E, et al. Identifying effective nurse-led care transition interventions for older adults with complex needs using a structured expert panel. Worldviews Evid Based Nurs 2017 Apr;14(2):136-144. [CrossRef] [Medline]
  107. Wright EA, Graham JH, Maeng D, Tusing L, Zaleski L, Martin R, et al. Reductions in 30-day readmission, mortality, and costs with inpatient-to-community pharmacist follow-up. J Am Pharm Assoc (2003) 2019;59(2):178-186. [CrossRef] [Medline]
  108. Warren C, Lemieux AA, Phoenix Bittner N. Excellence in population health: a successful community-based care transitions program model. Prof Case Manag 2019;24(1):39-45. [CrossRef] [Medline]
  109. Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. The care span: the importance of transitional care in achieving health reform. Health Aff (Millwood) 2011 Apr;30(4):746-754. [CrossRef] [Medline]
  110. Hjelm M, Holst G, Willman A, Bohman D, Kristensson J. The work of case managers as experienced by older persons (75+) with multi-morbidity - a focused ethnography. BMC Geriatr 2015 Dec 17;15:168 [FREE Full text] [CrossRef] [Medline]
  111. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009 Jul 21;6(7):e1000097 [FREE Full text] [CrossRef] [Medline]
  112. Amir O, Ben-Gal T, Weinstein JM, Schliamser J, Burkhoff D, Abbo A, et al. Evaluation of remote dielectric sensing (ReDS) technology-guided therapy for decreasing heart failure re-hospitalizations. Int J Cardiol 2017 Aug 01;240:279-284 [FREE Full text] [CrossRef] [Medline]
  113. Ammenwerth E, Woess S, Baumgartner C, Fetz B, van der Heidt A, Kastner P, et al. Evaluation of an integrated telemonitoring surveillance system in patients with coronary heart disease. Methods Inf Med 2015;54(5):388-397. [CrossRef] [Medline]
  114. Amroze A, Field TS, Fouayzi H, Sundaresan D, Burns L, Garber L, et al. Use of electronic health record access and audit logs to identify physician actions following noninterruptive alert opening: descriptive study. JMIR Med Inform 2019 Feb 07;7(1):e12650 [FREE Full text] [CrossRef] [Medline]
  115. Andikyan V, Rezk Y, Einstein MH, Gualtiere G, Leitao Jr MM, Sonoda Y, et al. A prospective study of the feasibility and acceptability of a Web-based, electronic patient-reported outcome system in assessing patient recovery after major gynecologic cancer surgery. Gynecol Oncol 2012 Nov;127(2):273-277 [FREE Full text] [CrossRef] [Medline]
  116. Arcilla D, Levin D, Sperber M. Transitioning patients to independence. Home Healthc Now 2019;37(3):158-164. [CrossRef] [Medline]
  117. Avery KN, Richards HS, Portal A, Reed T, Harding R, Carter R, et al. Developing a real-time electronic symptom monitoring system for patients after discharge following cancer-related surgery. BMC Cancer 2019 May 17;19(1):463 [FREE Full text] [CrossRef] [Medline]
  118. Aziz O, Atallah L, Lo B, Gray E, Athanasiou T, Darzi A, et al. Ear-worn body sensor network device: an objective tool for functional postoperative home recovery monitoring. J Am Med Inform Assoc 2011;18(2):156-159 [FREE Full text] [CrossRef] [Medline]
  119. Backman C, Harley A, Kuziemsky C, Mercer J, Peyton L. MyPath to home Web-based application for the geriatric rehabilitation program at Bruyère continuing care: user-centered design and feasibility testing study. JMIR Form Res 2020 Sep 14;4(9):e18169 [FREE Full text] [CrossRef] [Medline]
  120. Barken TL, Thygesen E, Söderhamn U. Unlocking the limitations: living with chronic obstructive pulmonary disease and receiving care through telemedicine-a phenomenological study. J Clin Nurs 2018 Jan;27(1-2):132-142. [CrossRef] [Medline]
  121. Barnason S, Zimmerman L, Schulz P, Pullen C, Schuelke S. Weight management telehealth intervention for overweight and obese rural cardiac rehabilitation participants: a randomised trial. J Clin Nurs 2019 May;28(9-10):1808-1818 [FREE Full text] [CrossRef] [Medline]
  122. Bednarski BK, Nickerson TP, You YN, Messick CA, Speer B, Gottumukkala V, et al. Randomized clinical trial of accelerated enhanced recovery after minimally invasive colorectal cancer surgery (RecoverMI trial). Br J Surg 2019 Sep;106(10):1311-1318 [FREE Full text] [CrossRef] [Medline]
  123. Belarmino A, Walsh R, Alshak M, Patel N, Wu R, Hu JC. Feasibility of a mobile health application to monitor recovery and patient-reported outcomes after robot-assisted radical prostatectomy. Eur Urol Oncol 2019 Jul;2(4):425-428. [CrossRef] [Medline]
  124. Bernocchi P, Vanoglio F, Baratti D, Morini R, Rocchi S, Luisa A, et al. Home-based telesurveillance and rehabilitation after stroke: a real-life study. Top Stroke Rehabil 2016 Apr;23(2):106-115. [CrossRef] [Medline]
  125. Bernocchi P, Scalvini S, Tridico C, Borghi G, Zanaboni P, Masella C, et al. Healthcare continuity from hospital to territory in Lombardy: TELEMACO project. Am J Manag Care 2012 Mar 01;18(3):e101-e108 [FREE Full text] [Medline]
  126. Boeni F, Hersberger KE, Arnet I. Success of a sustained pharmaceutical care service with electronic adherence monitoring in patient with diabetes over 12 months. BMJ Case Rep 2015 Jun 02;2015:bcr2014208672 [FREE Full text] [CrossRef] [Medline]
  127. Book K, Dinkel A, Henrich G, Stuhr C, Peuker M, Härtl K, et al. The effect of including a 'psychooncological statement' in the discharge summary on patient-physician communication: a randomized controlled trial. Psychooncology 2013 Dec;22(12):2789-2796. [CrossRef] [Medline]
  128. Bouwsma EV, Huirne JA, van de Ven PM, Vonk Noordegraaf A, Schaafsma FG, Schraffordt Koops SE, et al. Effectiveness of an Internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: cluster controlled trial with randomised stepped-wedge implementation. BMJ Open 2018 Jan 30;8(1):e017781 [FREE Full text] [CrossRef] [Medline]
  129. Campbell KJ, Louie PK, Bohl DD, Edmiston T, Mikhail C, Li J, et al. A novel, automated text-messaging system is effective in patients undergoing total joint arthroplasty. J Bone Joint Surg Am 2019 Jan 16;101(2):145-151. [CrossRef] [Medline]
  130. Carrier G, Cotte E, Beyer-Berjot L, Faucheron JL, Joris J, Slim K, Groupe Francophone de Réhabilitation Améliorée après Chirurgie (GRACE). Post-discharge follow-up using text messaging within an enhanced recovery program after colorectal surgery. J Visc Surg 2016 Aug;153(4):249-252 [FREE Full text] [CrossRef] [Medline]
  131. Chang YL, Tsai YF, Hsu CL, Chao YK, Hsu CC, Lin KC. The effectiveness of a nurse-led exercise and health education informatics program on exercise capacity and quality of life among cancer survivors after esophagectomy: a randomized controlled trial. Int J Nurs Stud 2020 Jan;101:103418. [CrossRef] [Medline]
  132. Chen Y, Brennan N, Magrabi F. Is email an effective method for hospital discharge communication? A randomized controlled trial to examine delivery of computer-generated discharge summaries by email, fax, post and patient hand delivery. Int J Med Inform 2010 Mar;79(3):167-172. [CrossRef] [Medline]
  133. Chen C, Li X, Sun L, Cao S, Kang Y, Hong L, et al. Post-discharge short message service improves short-term clinical outcome and self-care behaviour in chronic heart failure. ESC Heart Fail 2019 Feb;6(1):164-173 [FREE Full text] [CrossRef] [Medline]
  134. Chiang LC, Chen WC, Dai YT, Ho YL. The effectiveness of telehealth care on caregiver burden, mastery of stress, and family function among family caregivers of heart failure patients: a quasi-experimental study. Int J Nurs Stud 2012 Oct;49(10):1230-1242. [CrossRef] [Medline]
  135. Cox CE, Hough CL, Carson SS, White DB, Kahn JM, Olsen MK, et al. Effects of a telephone- and Web-based coping skills training program compared with an education program for survivors of critical illness and their family members. A randomized clinical trial. Am J Respir Crit Care Med 2018 Jan 01;197(1):66-78. [CrossRef] [Medline]
  136. Cox CE, Hough CL, Jones DM, Ungar A, Reagan W, Key MD, et al. Effects of mindfulness training programmes delivered by a self-directed mobile app and by telephone compared with an education programme for survivors of critical illness: a pilot randomised clinical trial. Thorax 2019 Jan;74(1):33-42 [FREE Full text] [CrossRef] [Medline]
  137. Davis C, Bender M, Smith T, Broad J. Feasibility and acute care utilization outcomes of a post-acute transitional telemonitoring program for underserved chronic disease patients. Telemed J E Health 2015 Sep;21(9):705-713. [CrossRef] [Medline]
  138. Day MA, Anthony CA, Bedard NA, Glass NA, Clark CR, Callaghan JJ, et al. Increasing perioperative communication with automated mobile phone messaging in total joint arthroplasty. J Arthroplasty 2018 Jan;33(1):19-24. [CrossRef] [Medline]
  139. Dendale P, De Keulenaer G, Troisfontaines P, Weytjens C, Mullens W, Elegeert I, et al. Effect of a telemonitoring-facilitated collaboration between general practitioner and heart failure clinic on mortality and rehospitalization rates in severe heart failure: the TEMA-HF 1 (TElemonitoring in the MAnagement of Heart Failure) study. Eur J Heart Fail 2012 Mar;14(3):333-340 [FREE Full text] [CrossRef] [Medline]
  140. DeVito Dabbs A, Song MK, Myers BA, Li R, Hawkins RP, Pilewski JM, et al. A randomized controlled trial of a mobile health intervention to promote self-management after lung transplantation. Am J Transplant 2016 Jul;16(7):2172-2180 [FREE Full text] [CrossRef] [Medline]
  141. DeVon HA, Rankin SH, Paul SM, Ochs AL. Heart Lung 2010;39(6 Suppl):S23-S33. [CrossRef] [Medline]
  142. Dexter C, Bradley B, Williams DH. Online follow-up after total hip replacement: a first case. BMJ Case Rep 2013 Feb 08;2013:bcr2012008163 [FREE Full text] [CrossRef] [Medline]
  143. Andrew DG, Puls SE, Guerrero KS. Utilizing information technology to improve transition of care from hospital to home. J Nurs Educ Pract 2016 Feb 16;6(6):61. [CrossRef]
  144. Duncan PW, Abbott RM, Rushing S, Johnson AM, Condon CN, Lycan SL, COMPASS Investigative Team. COMPASS-CP: an electronic application to capture patient-reported outcomes to develop actionable stroke and transient ischemic attack care plans. Circ Cardiovasc Qual Outcomes 2018 Aug;11(8):e004444. [CrossRef] [Medline]
  145. Dunn AS, Shetreat-Klein A, Berman J, Cho HJ, Stein L, Lewis C, et al. Improving transitions of care for patients on warfarin: the safe transitions anticoagulation report. J Hosp Med 2015 Sep;10(9):615-618. [CrossRef] [Medline]
  146. Evangelista LS, Lee JA, Moore AA, Motie M, Ghasemzadeh H, Sarrafzadeh M, et al. Examining the effects of remote monitoring systems on activation, self-care, and quality of life in older patients with chronic heart failure. J Cardiovasc Nurs 2015;30(1):51-57 [FREE Full text] [CrossRef] [Medline]
  147. Fitzsimmons DA, Thompson J, Bentley CL, Mountain GA. Comparison of patient perceptions of Telehealth-supported and specialist nursing interventions for early stage COPD: a qualitative study. BMC Health Serv Res 2016 Aug 22;16(1):420 [FREE Full text] [CrossRef] [Medline]
  148. Frail CK, Garza OW, Haas AL. Experience with technology-supported transitions of care to improve medication use. J Am Pharm Assoc (2003) 2016;56(5):568-572. [CrossRef] [Medline]
  149. Gesell SB, Bushnell CD, Jones SB, Coleman SW, Levy SM, Xenakis JG, et al. Implementation of a billable transitional care model for stroke patients: the COMPASS study. BMC Health Serv Res 2019 Dec 19;19(1):978 [FREE Full text] [CrossRef] [Medline]
  150. Gunter RL, Fernandes-Taylor S, Rahman S, Awoyinka L, Bennett KM, Weber SM, et al. Feasibility of an image-based mobile health protocol for postoperative wound monitoring. J Am Coll Surg 2018 Mar;226(3):277-286 [FREE Full text] [CrossRef] [Medline]
  151. Gustavell T, Sundberg K, Segersvärd R, Wengström Y, Langius-Eklöf A. Decreased symptom burden following surgery due to support from an interactive app for symptom management for patients with pancreatic and periampullary cancer. Acta Oncol 2019 Sep;58(9):1307-1314. [CrossRef] [Medline]
  152. Gustavell T, Langius-Eklöf A, Wengström Y, Segersvärd R, Sundberg K. Development and feasibility of an interactive smartphone app for early assessment and management of symptoms following pancreaticoduodenectomy. Cancer Nurs 2019;42(3):E1-10. [CrossRef] [Medline]
  153. Haynes SC, Tancredi DJ, Tong K, Hoch JS, Ong MK, Ganiats TG, Better Effectiveness After Transition–Heart Failure (BEAT-HF) Research Group. Association of adherence to weight telemonitoring with health care use and death: a secondary analysis of a randomized clinical trial. JAMA Netw Open 2020 Jul 01;3(7):e2010174 [FREE Full text] [CrossRef] [Medline]
  154. Heaton PC, Frede S, Kordahi A, Lowery L, Moorhead B, Kirby J, et al. Improving care transitions through medication therapy management: a community partnership to reduce readmissions in multiple health-systems. J Am Pharm Assoc (2003) 2019;59(3):319-328. [CrossRef] [Medline]
  155. Heiney SP, Donevant SB, Arp Adams S, Parker PD, Chen H, Levkoff S. A smartphone app for self-management of heart failure in older African Americans: feasibility and usability study. JMIR Aging 2020 Apr 03;3(1):e17142 [FREE Full text] [CrossRef] [Medline]
  156. Hewner S. A population-based care transition model for chronically ill elders. Nurs Econ 2014;32(3):109-117. [Medline]
  157. Ho TW, Huang CT, Chiu HC, Ruan SY, Tsai YJ, Yu CJ, HINT Study Group. Effectiveness of telemonitoring in patients with chronic obstructive pulmonary disease in Taiwan-a randomized controlled trial. Sci Rep 2016 Mar 31;6:23797 [FREE Full text] [CrossRef] [Medline]
  158. Holleck JL, Gunderson CG, Antony SM, Gupta S, Chang JJ, Merchant N, et al. The "Hand-in" project: jump-starting communication between inpatient and outpatient providers. South Med J 2017 Nov;110(11):694-698. [CrossRef] [Medline]
  159. Holt JE, Flint EP, Bowers MT. Got the picture? Using mobile phone technology to reinforce discharge instructions. Am J Nurs 2011 Aug;111(8):47-51. [CrossRef] [Medline]
  160. Hu X, Zhu X, Gao L. Intensive nursing care by an electronic followup system to promote secondary prevention after percutaneous coronary intervention: a randomized trial. J Cardiopulm Rehabil Prev 2014;34(6):396-405. [CrossRef] [Medline]
  161. Jayaram NM, Khariton Y, Krumholz HM, Chaudhry SI, Mattera J, Tang F, et al. Impact of telemonitoring on health status. Circ Cardiovasc Qual Outcomes 2017 Dec;10(12):e004148 [FREE Full text] [CrossRef] [Medline]
  162. Choi J. Effect of pictograph-based discharge instructions on older adults' comprehension and recall: a pilot study. Res Gerontol Nurs 2016;9(2):66-71. [CrossRef] [Medline]
  163. Jonker LT, Plas M, de Bock GH, Buskens E, van Leeuwen BL, Lahr MM. Remote home monitoring of older surgical cancer patients: perspective on study implementation and feasibility. Ann Surg Oncol 2021 Jan;28(1):67-78 [FREE Full text] [CrossRef] [Medline]
  164. Kamoen O, Maqueda V, Yperzeele L, Pottel H, Cras P, Vanhooren G, et al. Stroke coach: a pilot study of a personal digital coaching program for patients after ischemic stroke. Acta Neurol Belg 2020 Feb;120(1):91-97. [CrossRef] [Medline]
  165. Kang YN, Shen HN, Lin CY, Elwyn G, Huang SC, Wu TF, et al. Does a mobile app improve patients' knowledge of stroke risk factors and health-related quality of life in patients with stroke? A randomized controlled trial. BMC Med Inform Decis Mak 2019 Dec 21;19(1):282 [FREE Full text] [CrossRef] [Medline]
  166. Karapinar-Çarkıt F, van Breukelen BR, Borgsteede SD, Janssen MJ, Egberts AC, van den Bemt PM. Completeness of patient records in community pharmacies post-discharge after in-patient medication reconciliation: a before-after study. Int J Clin Pharm 2014 Aug;36(4):807-814. [CrossRef] [Medline]
  167. Katz MH, Slack R, Bruno M, McMillan J, Fleming JB, Lee JE, et al. Outpatient virtual clinical encounters after complex surgery for cancer: a prospective pilot study of "TeleDischarge". J Surg Res 2016 May 01;202(1):196-203. [CrossRef] [Medline]
  168. Keeping-Burke L, Purden M, Frasure-Smith N, Cossette S, McCarthy F, Amsel R. Bridging the transition from hospital to home: effects of the VITAL telehealth program on recovery for CABG surgery patients and their caregivers. Res Nurs Health 2013 Dec;36(6):540-553. [CrossRef] [Medline]
  169. Khan D, Fjerbæk A, Andreasen JJ, Thorup CB, Dinesen B. Cardiac surgery patients’ e-health literacy and their use of a digital portal. Health Educ J 2018 Feb 19;77(4):482-494. [CrossRef]
  170. Klement MR, Rondon AJ, McEntee RM, Greenky MR, Austin MS. Web-based, self-directed physical therapy after total knee arthroplasty is safe and effective for most, but not all, patients. J Arthroplasty 2019 Jul;34(7S):S178-S182. [CrossRef] [Medline]
  171. Kogut SJ, Goldstein E, Charbonneau C, Jackson A, Patry G. Improving medication management after a hospitalization with pharmacist home visits and electronic personal health records: an observational study. Drug Healthc Patient Saf 2014 Jan 17;6:1-6 [FREE Full text] [CrossRef] [Medline]
  172. Lacson R, Desai S, Landman A, Proctor R, Sumption S, Khorasani R. Impact of a health information technology intervention on the follow-up management of pulmonary nodules. J Digit Imaging 2018 Feb;31(1):19-25 [FREE Full text] [CrossRef] [Medline]
  173. Layton AM, Whitworth J, Peacock J, Bartels MN, Jellen PA, Thomashow BM. Feasibility and acceptability of utilizing a smartphone based application to monitor outpatient discharge instruction compliance in cardiac disease patients around discharge from hospitalization. Int J Telemed Appl 2014;2014:415868 [FREE Full text] [CrossRef] [Medline]
  174. Ehnbom EC, Raban MZ, Walter SR, Richardson K, Westbrook JI. Do electronic discharge summaries contain more complete medication information? A retrospective analysis of paper versus electronic discharge summaries. Health Inf Manag 2014;43(3):4-12. [CrossRef] [Medline]
  175. Lin YH, Huang GS, Ho YL, Lou MF. Patient willingness to undergo a two-week free trial of a telemedicine service for coronary artery disease after coronary intervention: a mixed-methods study. J Nurs Manag 2020 Mar;28(2):407-416. [CrossRef] [Medline]
  176. Lindhardt T, Nielsen MH. Older patients' use of technology for a post-discharge nutritional intervention - a mixed-methods feasibility study. Int J Med Inform 2017 Jan;97:312-321. [CrossRef] [Medline]
  177. Lowres N, Mulcahy G, Gallagher R, Ben Freedman S, Marshman D, Kirkness A, et al. Self-monitoring for atrial fibrillation recurrence in the discharge period post-cardiac surgery using an iPhone electrocardiogram. Eur J Cardiothorac Surg 2016 Jul;50(1):44-51. [CrossRef] [Medline]
  178. Luo J, Dong X, Hu J. Effect of nursing intervention via a chatting tool on the rehabilitation of patients after Total hip Arthroplasty. J Orthop Surg Res 2019 Dec 09;14(1):417 [FREE Full text] [CrossRef] [Medline]
  179. Lyu KX, Zhao J, Wang B, Xiong GX, Yang WQ, Liu QH, et al. Smartphone application WeChat for clinical follow-up of discharged patients with head and neck tumors: a randomized controlled trial. Chin Med J (Engl) 2016 Dec 05;129(23):2816-2823 [FREE Full text] [CrossRef] [Medline]
  180. Madigan E, Schmotzer BJ, Struk CJ, DiCarlo CM, Kikano G, Piña IL, et al. Home health care with telemonitoring improves health status for older adults with heart failure. Home Health Care Serv Q 2013;32(1):57-74 [FREE Full text] [CrossRef] [Medline]
  181. Markle-Reid M, Valaitis R, Bartholomew A, Fisher K, Fleck R, Ploeg J, et al. An integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: a feasibility study. J Comorb 2020 Apr 22;10:2235042X19900451 [FREE Full text] [CrossRef] [Medline]
  182. Martirosov AL, Seitllari K, Kaurala S, MacDonald N. Pharmacist implementation of a transitions of care electronic referral process to provide hand-off between inpatient and outpatient settings. J Am Pharm Assoc (2003) 2020;60(1):112-6.e1. [CrossRef] [Medline]
  183. Mathar H, Fastholm P, Sandholm N. A qualitative study of televideo consultations for COPD patients. Br J Nurs 2015;24(4):205-209. [CrossRef] [Medline]
  184. McCloskey R, Jarrett P, Stewart C, Keeping-Burke L. Recruitment and retention challenges in a technology-based study with older adults discharged from a geriatric rehabilitation unit. Rehabil Nurs 2015;40(4):249-259. [CrossRef] [Medline]
  185. McGillion M, Ouellette C, Good A, Bird M, Henry S, Clyne W, et al. Postoperative remote automated monitoring and virtual Hospital-to-Home Care system following cardiac and major vascular surgery: user testing study. J Med Internet Res 2020 Mar 18;22(3):e15548 [FREE Full text] [CrossRef] [Medline]
  186. Melholt C, Joensson K, Spindler H, Hansen J, Andreasen JJ, Nielsen G, et al. Cardiac patients' experiences with a telerehabilitation web portal: implications for eHealth literacy. Patient Educ Couns 2018 May;101(5):854-861. [CrossRef] [Medline]
  187. Wang MY, Shen MJ, Wan LH, Mo MM, Wu Z, Li LL, et al. Effects of a comprehensive reminder system based on the health belief model for patients who have had a stroke on health behaviors, blood pressure, disability, and recurrence from baseline to 6 months: a randomized controlled trial. J Cardiovasc Nurs 2020;35(2):156-164. [CrossRef] [Medline]
  188. Metcalf M, Glazyrine V, Glavin K, Dahlgren A, Michael C, Bechtel M, et al. The feasibility of a health care application in the treatment of patients undergoing radical cystectomy. J Urol 2019 May;201(5):902-908. [CrossRef] [Medline]
  189. Moffet H, Tousignant M, Nadeau S, Mérette C, Boissy P, Corriveau H, et al. In-home telerehabilitation compared with face-to-face rehabilitation after total knee arthroplasty: a noninferiority randomized controlled trial. J Bone Joint Surg Am 2015 Jul 15;97(14):1129-1141. [CrossRef] [Medline]
  190. Moro Agud M, Menéndez Colino R, Mauleón Ladrero MD, Ruano Encinar M, Díez Sebastián J, Villamañán Bueno E, et al. Analysis of an electronic medication reconciliation and information at discharge programme for frail elderly patients. Int J Clin Pharm 2016 Aug;38(4):996-1001. [CrossRef] [Medline]
  191. Mousa AY, Broce M, Monnett S, Davis E, McKee B, Lucas BD. Results of telehealth electronic monitoring for post discharge complications and surgical site infections following arterial revascularization with groin incision. Ann Vasc Surg 2019 May;57:160-169. [CrossRef] [Medline]
  192. Moy NY, Lee SJ, Chan T, Grovey B, Boscardin WJ, Gonzales R, et al. Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project. Jt Comm J Qual Patient Saf 2014 May;40(5):219-227. [CrossRef] [Medline]
  193. Nazar H, Brice S, Akhter N, Kasim A, Gunning A, Slight SP, et al. New transfer of care initiative of electronic referral from hospital to community pharmacy in England: a formative service evaluation. BMJ Open 2016 Oct 14;6(10):e012532 [FREE Full text] [CrossRef] [Medline]
  194. Newnham HH, Gibbs HH, Ritchie ES, Hitchcock KI, Nagalingam V, Hoiles A, et al. A feasibility study of the provision of a personalized interdisciplinary audiovisual summary to facilitate care transfer care at hospital discharge: Care Transfer Video (CareTV). Int J Qual Health Care 2015 Apr;27(2):105-109. [CrossRef] [Medline]
  195. Nielsen C, Agerskov H, Bistrup C, Clemensen J. Evaluation of a telehealth solution developed to improve follow-up after kidney transplantation. J Clin Nurs 2020 Apr;29(7-8):1053-1063. [CrossRef] [Medline]
  196. Nilsson L, Hellström A, Wennerberg C, Ekstedt M, Schildmeijer K. Patients' experiences of using an e-Health tool for self-management support after prostate cancer surgery: a deductive interview study explained through the FITT framework. BMJ Open 2020 Jun 29;10(6):e035024 [FREE Full text] [CrossRef] [Medline]
  197. Nundy S, Razi RR, Dick JJ, Smith B, Mayo A, O'Connor A, et al. A text messaging intervention to improve heart failure self-management after hospital discharge in a largely African-American population: before-after study. J Med Internet Res 2013 Mar 11;15(3):e53 [FREE Full text] [CrossRef] [Medline]
  198. Ong MK, Romano PS, Edgington S, Aronow HU, Auerbach AD, Black JT, Better Effectiveness After Transition–Heart Failure (BEAT-HF) Research Group. Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure: the Better Effectiveness After Transition -- Heart Failure (BEAT-HF) randomized clinical trial. JAMA Intern Med 2016 Mar;176(3):310-318 [FREE Full text] [CrossRef] [Medline]
  199. Ostrovsky A, O'Connor L, Marshall O, Angelo A, Barrett K, Majeski E, et al. Predicting 30- to 120-day readmission risk among Medicare fee-for-service patients using nonmedical workers and mobile technology. Perspect Health Inf Manag 2016 Jan 1;13(Winter):1e [FREE Full text] [Medline]
  200. Park KH, Song MR. The effects of postdischarge telephone counseling and short message service on the knee function, activities of daily living, and life satisfaction of patients undergoing total knee replacement. Orthop Nurs 2017;36(3):229-236 [FREE Full text] [CrossRef] [Medline]
  201. Pastora-Bernal JM, Martín-Valero R, Barón-López FJ, Moyano NG, Estebanez-Pérez MJ. Telerehabilitation after arthroscopic subacromial decompression is effective and not inferior to standard practice: preliminary results. J Telemed Telecare 2018 Jul;24(6):428-433. [CrossRef] [Medline]
  202. Pavic M, Klaas V, Theile G, Kraft J, Tröster G, Guckenberger M. Feasibility and usability aspects of continuous remote monitoring of health status in palliative cancer patients using wearables. Oncology 2020;98(6):386-395 [FREE Full text] [CrossRef] [Medline]
  203. Pavic M, Klaas V, Theile G, Kraft J, Tröster G, Blum D, et al. Mobile health technologies for continuous monitoring of cancer patients in palliative care aiming to predict health status deterioration: a feasibility study. J Palliat Med 2020 May;23(5):678-685. [CrossRef] [Medline]
  204. Pedone C, Rossi FF, Cecere A, Costanzo L, Antonelli Incalzi R. Efficacy of a physician-led multiparametric telemonitoring system in very old adults with heart failure. J Am Geriatr Soc 2015 Jun;63(6):1175-1180. [CrossRef] [Medline]
  205. Piau A, Crissey R, Brechemier D, Balardy L, Nourhashemi F. A smartphone Chatbot application to optimize monitoring of older patients with cancer. Int J Med Inform 2019 Aug;128:18-23. [CrossRef] [Medline]
  206. Piette JD, Striplin D, Fisher L, Aikens JE, Lee A, Marinec N, et al. Effects of accessible health technology and caregiver support posthospitalization on 30-day readmission risk: a randomized trial. Jt Comm J Qual Patient Saf 2020 Feb;46(2):109-117 [FREE Full text] [CrossRef] [Medline]
  207. Ponce BA, Brabston EW, Zu S, Watson SL, Baker D, Winn D, et al. Telemedicine with mobile devices and augmented reality for early postoperative care. Annu Int Conf IEEE Eng Med Biol Soc 2016 Aug;2016:4411-4414. [CrossRef] [Medline]
  208. Prince M, Allen D, Chittenden S, Misuraca J, Hockenberry MJ. Improving transitional care: the role of handoffs and discharge checklists in hematologic malignancies. Clin J Oncol Nurs 2019 Feb 01;23(1):36-42. [CrossRef] [Medline]
  209. Ramkumar K, Perera MT, Marudanayagam R, Coldham C, Olliff SP, Mayer DA, et al. A reaudit of specialist-managed liver trauma after establishment of regional referral and management guidelines. J Trauma 2010 Jan;68(1):84-89. [CrossRef] [Medline]
  210. Reed M, Huang J, Brand R, Graetz I, Jaffe MG, Ballard D, et al. Inpatient-outpatient shared electronic health records: telemedicine and laboratory follow-up after hospital discharge. Am J Manag Care 2020 Oct 01;26(10):e327-e332 [FREE Full text] [CrossRef] [Medline]
  211. Reider-Demer M, Raja P, Martin N, Schwinger M, Babayan D. Prospective and retrospective study of videoconference telemedicine follow-up after elective neurosurgery: results of a pilot program. Neurosurg Rev 2018 Apr;41(2):497-501. [CrossRef] [Medline]
  212. Requena M, Montiel E, Baladas M, Muchada M, Boned S, López R, et al. Farmalarm. Stroke 2019 Jul;50(7):1819-1824. [CrossRef] [Medline]
  213. Ritchie CS, Houston TK, Richman JS, Sobko HJ, Berner ES, Taylor BB, et al. The E-Coach technology-assisted care transition system: a pragmatic randomized trial. Transl Behav Med 2016 Sep;6(3):428-437 [FREE Full text] [CrossRef] [Medline]
  214. Sabir FR, Tomlinson J, Strickland-Hodge B, Smith H. Evaluating the connect with pharmacy Web-based intervention to reduce hospital readmission for older people. Int J Clin Pharm 2019 Oct;41(5):1239-1246 [FREE Full text] [CrossRef] [Medline]
  215. Saleh S, Larsen JP, Bergsåker-Aspøy J, Grundt H. Re-admissions to hospital and patient satisfaction among patients with chronic obstructive pulmonary disease after telemedicine video consultation - a retrospective pilot study. Multidiscip Respir Med 2014 Jan 30;9(1):6 [FREE Full text] [CrossRef] [Medline]
  216. Santana MJ, Holroyd-Leduc J, Southern DA, Flemons WW, O'Beirne M, Hill MD, e-DCT Team. A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission. BMJ Qual Saf 2017 Dec;26(12):993-1003. [CrossRef] [Medline]
  217. Scheper H, Derogee R, Mahdad R, van der Wal RJ, Nelissen RG, Visser LG, et al. A mobile app for postoperative wound care after arthroplasty: ease of use and perceived usefulness. Int J Med Inform 2019 Sep;129:75-80. [CrossRef] [Medline]
  218. Schneider MA, Howard KA. Using technology to enhance discharge teaching and improve coping for patients after stroke. J Neurosci Nurs 2017 Jun;49(3):152-156. [CrossRef] [Medline]
  219. Sinha S, Dillon J, Dargar SK, Archambault A, Martin P, Frankel BA, et al. What to expect that you're not expecting: a pilot video education intervention to improve patient self-efficacy surrounding discharge medication barriers. Health Informatics J 2019 Dec;25(4):1595-1605 [FREE Full text] [CrossRef] [Medline]
  220. Smith KJ, Handler SM, Kapoor WN, Martich GD, Reddy VK, Clark S. Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors. Am J Med Qual 2016 Jul;31(4):315-322 [FREE Full text] [CrossRef] [Medline]
  221. Sorknaes AD, Madsen H, Hallas J, Jest P, Hansen-Nord M. Nurse tele-consultations with discharged COPD patients reduce early readmissions--an interventional study. Clin Respir J 2011 Jan;5(1):26-34. [CrossRef] [Medline]
  222. Sorknaes AD, Bech M, Madsen H, Titlestad IL, Hounsgaard L, Hansen-Nord M, et al. The effect of real-time teleconsultations between hospital-based nurses and patients with severe COPD discharged after an exacerbation. J Telemed Telecare 2013 Dec;19(8):466-474. [CrossRef] [Medline]
  223. Sui Y, Wang T, Wang X. The impact of WeChat app-based education and rehabilitation program on anxiety, depression, quality of life, loss of follow-up and survival in non-small cell lung cancer patients who underwent surgical resection. Eur J Oncol Nurs 2020 Apr;45:101707. [CrossRef] [Medline]
  224. Sun V, Dumitra S, Ruel N, Lee B, Melstrom L, Melstrom K, et al. Wireless monitoring program of patient-centered outcomes and recovery before and after major abdominal cancer surgery. JAMA Surg 2017 Sep 01;152(9):852-859 [FREE Full text] [CrossRef] [Medline]
  225. Sun V, Raz DJ, Ruel N, Chang W, Erhunmwunsee L, Reckamp K, et al. A multimedia self-management intervention to prepare cancer patients and family caregivers for lung surgery and postoperative recovery. Clin Lung Cancer 2017 May;18(3):e151-e159 [FREE Full text] [CrossRef] [Medline]
  226. Tamblyn R, Abrahamowicz M, Buckeridge DL, Bustillo M, Forster AJ, Girard N, et al. Effect of an electronic medication reconciliation intervention on adverse drug events: a cluster randomized trial. JAMA Netw Open 2019 Sep 04;2(9):e1910756 [FREE Full text] [CrossRef] [Medline]
  227. Tamblyn R, Winslade N, Lee TC, Motulsky A, Meguerditchian A, Bustillo M, et al. Improving patient safety and efficiency of medication reconciliation through the development and adoption of a computer-assisted tool with automated electronic integration of population-based community drug data: the RightRx project. J Am Med Inform Assoc 2018 May 01;25(5):482-495 [FREE Full text] [CrossRef] [Medline]
  228. Timmers T, Janssen L, van der Weegen W, Das D, Marijnissen WJ, Hannink G, et al. The effect of an app for day-to-day postoperative care education on patients with total knee replacement: randomized controlled trial. JMIR Mhealth Uhealth 2019 Oct 21;7(10):e15323 [FREE Full text] [CrossRef] [Medline]
  229. Treskes RW, van Winden LA, van Keulen N, van der Velde ET, Beeres SL, Atsma DE, et al. Effect of smartphone-enabled health monitoring devices vs regular follow-up on blood pressure control among patients after myocardial infarction: a randomized clinical trial. JAMA Netw Open 2020 Apr 01;3(4):e202165 [FREE Full text] [CrossRef] [Medline]
  230. van den Berg M, Crotty M, Liu E, Killington M, Kwakkel G, van Wegen E. Early supported discharge by caregiver-mediated exercises and e-health support after stroke: a proof-of-concept trial. Stroke 2016 Jul;47(7):1885-1892. [CrossRef] [Medline]
  231. van der Meij E, Anema JR, Leclercq WK, Bongers MY, Consten EC, Schraffordt Koops SE, et al. Personalised perioperative care by e-health after intermediate-grade abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trial. Lancet 2018 Jul 07;392(10141):51-59. [CrossRef] [Medline]
  232. Vest JR, Kern LM, Silver MD, Kaushal R, HITEC investigators. The potential for community-based health information exchange systems to reduce hospital readmissions. J Am Med Inform Assoc 2015 Mar;22(2):435-442. [CrossRef] [Medline]
  233. Vesterby MS, Pedersen PU, Laursen M, Mikkelsen S, Larsen J, Søballe K, et al. Telemedicine support shortens length of stay after fast-track hip replacement. Acta Orthop 2017 Feb;88(1):41-47 [FREE Full text] [CrossRef] [Medline]
  234. Vianello A, Fusello M, Gubian L, Rinaldo C, Dario C, Concas A, et al. Home telemonitoring for patients with acute exacerbation of chronic obstructive pulmonary disease: a randomized controlled trial. BMC Pulm Med 2016 Nov 22;16(1):157 [FREE Full text] [CrossRef] [Medline]
  235. Villani A, Malfatto G, Compare A, Della Rosa F, Bellardita L, Branzi G, et al. Clinical and psychological telemonitoring and telecare of high risk heart failure patients. J Telemed Telecare 2014 Dec;20(8):468-475. [CrossRef] [Medline]
  236. Wade R, Cartwright C, Shaw K. Factors relating to home telehealth acceptance and usage compliance. Risk Manag Healthc Policy 2012;5:25-33 [FREE Full text] [CrossRef] [Medline]
  237. Wang L, He L, Tao Y, Sun L, Zheng H, Zheng Y, et al. Evaluating a Web-based coaching program using electronic health records for patients with chronic obstructive pulmonary disease in China: randomized controlled trial. J Med Internet Res 2017 Jul 21;19(7):e264 [FREE Full text] [CrossRef] [Medline]
  238. Wang QQ, Zhao J, Huo XR, Wu L, Yang LF, Li JY, et al. Effects of a home care mobile app on the outcomes of discharged patients with a stoma: a randomised controlled trial. J Clin Nurs 2018 Oct;27(19-20):3592-3602. [CrossRef] [Medline]
  239. Wang J, Tong Y, Jiang Y, Zhu H, Gao H, Wei R, et al. The effectiveness of extended care based on Internet and home care platform for orthopaedics after hip replacement surgery in China. J Clin Nurs 2018 Nov;27(21-22):4077-4088. [CrossRef] [Medline]
  240. Wan LH, Zhang XP, You LM, Ruan HF, Chen SX. The efficacy of a comprehensive reminder system to improve health behaviors and blood pressure control in hypertensive ischemic stroke patients: a randomized controlled trial. J Cardiovasc Nurs 2018;33(6):509-517. [CrossRef] [Medline]
  241. Whitehouse CR, Long JA, Maloney LM, Daniels K, Horowitz DA, Bowles KH. Feasibility of diabetes self-management telehealth education for older adults during transitions in care. Res Gerontol Nurs 2020 May 01;13(3):138-145 [FREE Full text] [CrossRef] [Medline]
  242. Wilcock M, Hill A, Wynn A, Kelly L. Accuracy of pharmacist electronic discharge medicines review information transmitted to primary care at discharge. Int J Clin Pharm 2019 Jun;41(3):820-824. [CrossRef] [Medline]
  243. Zheng QY, Geng L, Ni M, Sun JY, Ren P, Ji QB, et al. Modern instant messaging platform for postoperative follow-up of patients after total joint arthroplasty may reduce re-admission rate. J Orthop Surg Res 2019 Dec 27;14(1):464 [FREE Full text] [CrossRef] [Medline]
  244. Zhou K, Li J, Li X. Effects of cyclic adjustment training delivered via a mobile device on psychological resilience, depression, and anxiety in Chinese post-surgical breast cancer patients. Breast Cancer Res Treat 2019 Nov;178(1):95-103. [CrossRef] [Medline]
  245. Zhou K, Wang W, Zhao W, Li L, Zhang M, Guo P, et al. Benefits of a WeChat-based multimodal nursing program on early rehabilitation in postoperative women with breast cancer: a clinical randomized controlled trial. Int J Nurs Stud 2020 Jun;106:103565. [CrossRef] [Medline]
  246. Khan A, Uddin S, Srinivasan U. Comorbidity network for chronic disease: a novel approach to understand type 2 diabetes progression. Int J Med Inform 2018 Jul;115:1-9. [CrossRef] [Medline]
  247. Lyu WB, Gao Y, Cheng KY, Wu R, Zhou WQ. Effect of self-acupoint massage on blood glucose level and quality of life in older adults with type 2 diabetes mellitus: a randomized controlled trial. J Gerontol Nurs 2019 Aug 01;45(8):43-48. [CrossRef] [Medline]
  248. Gagnon MP, Desmartis M, Labrecque M, Car J, Pagliari C, Pluye P, et al. Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals. J Med Syst 2012 Feb;36(1):241-277 [FREE Full text] [CrossRef] [Medline]
  249. Charles L, Jensen L, Torti JM, Parmar J, Dobbs B, Tian PG. Improving transitions from acute care to home among complex older adults using the LACE Index and care coordination. BMJ Open Qual 2020 Jun;9(2):e000814 [FREE Full text] [CrossRef] [Medline]
  250. Aase K, Waring J. Crossing boundaries: establishing a framework for researching quality and safety in care transitions. Appl Ergon 2020 Nov;89:103228 [FREE Full text] [CrossRef] [Medline]
  251. Nelson ML, Armas A, Thombs R, Singh H, Fulton J, Cunningham HV, et al. Synthesising evidence regarding hospital to home transitions supported by volunteers of third sector organisations: a scoping review protocol. BMJ Open 2021 Jul 05;11(7):e050479 [FREE Full text] [CrossRef] [Medline]
  252. Olsen RM, Hellzén O, Skotnes LH, Enmarker I. Breakdown in informational continuity of care during hospitalization of older home-living patients: a case study. Int J Integr Care 2014 Apr;14:e012 [FREE Full text] [CrossRef] [Medline]
  253. Coleman GW, Gibson L, Hanson VL, Bobrowicz A, McKay A. Engaging the disengaged: how do we design technology for digitally excluded older adults? In: Proceedings of the 8th ACM Conference on Designing Interactive Systems. 2010 Aug Presented at: DIS '10; August 16-20, 2010; Aarhus, Denmark p. 175-178. [CrossRef]
  254. Rogers WA, Fisk AD. Toward a psychological science of advanced technology design for older adults. J Gerontol B Psychol Sci Soc Sci 2010 Nov;65(6):645-653 [FREE Full text] [CrossRef] [Medline]
  255. Mannheim I, Schwartz E, Xi W, Buttigieg SC, McDonnell-Naughton M, Wouters EJ, et al. Inclusion of older adults in the research and design of digital technology. Int J Environ Res Public Health 2019 Oct 02;16(19):3718 [FREE Full text] [CrossRef] [Medline]
  256. Tappen RM, Cooley ME, Luckmann R, Panday S. Digital health information disparities in older adults: a mixed methods study. J Racial Ethn Health Disparities 2022 Feb;9(1):82-92 [FREE Full text] [CrossRef] [Medline]
  257. Jiang X, Ming WK, You JH. The cost-effectiveness of digital health interventions on the management of cardiovascular diseases: systematic review. J Med Internet Res 2019 Jun 17;21(6):e13166 [FREE Full text] [CrossRef] [Medline]
  258. Waffenschmidt S, Knelangen M, Sieben W, Bühn S, Pieper D. Single screening versus conventional double screening for study selection in systematic reviews: a methodological systematic review. BMC Med Res Methodol 2019 Jun 28;19(1):132 [FREE Full text] [CrossRef] [Medline]
  259. Hong QN, Pluye P, Fàbregues S, Bartlett G, Boardman F, Cargo M, et al. Improving the content validity of the mixed methods appraisal tool: a modified e-Delphi study. J Clin Epidemiol 2019 Jul;111:49-59.e1 [FREE Full text] [CrossRef] [Medline]
  260. Hong QN, Pluye P, Fàbregues S, Bartlett G, Boardman F, Cargo M, et al. Mixed methods appraisal tool (MMAT), version 2018: user guide. Department of Family Medicine, McGill University. 2018 Aug 1.   URL: http:/​/mixedmethodsappraisaltool public.​​w/​file/​fetch/​127916259/​MMAT_2018_criteria-manual_2018-08-01_ENG.​pdf [accessed 2021-01-29]

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
PRISMA-S: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Literature Search

Edited by J Wang; submitted 06.01.22; peer-reviewed by J Wang, V Sun; comments to author 14.03.22; accepted 06.04.22; published 19.05.22


©Hardeep Singh, Terence Tang, Carolyn Steele Gray, Kristina Kokorelias, Rachel Thombs, Donna Plett, Matthew Heffernan, Carlotta M Jarach, Alana Armas, Susan Law, Heather V Cunningham, Jason Xin Nie, Moriah E Ellen, Kednapa Thavorn, Michelle LA Nelson. Originally published in JMIR Aging (, 19.05.2022.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Aging, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.