| Study ID | Components of the assessment and implementation of the discharge plan | Aim, focus and content of the discharge plan | Follow‐up as part of the discharge planning intervention | Control group care |
| Balaban 2008 | Discharge planning lead: discharge planner registered nurse Timing of discharge plan: enrolled at admission to hospital Education:a patient discharge form for the patient that included information about the patient's health problem/diagnosis, medications, and follow‐up care Implementation of the discharge plan: discharge form was sent electronically to the primary care team to become part of the permanent medical records. | A discharge plan to improve communication between inpatient and outpatient care teams abd to reconnect patients who lived at home with their primary care team, using a structure‐process‐outcome approach. The intervention was structured for a culturally diverse population. | Telephone call: the day after discharge from hospital, from the primary care nurse | No communication between hospital and primary care nurse, handwritten discharge instruction in English, communication with hospital and primary care physician as required. |
| Bolas 2004 | Discharge planning lead: one full‐time clinical pharmacist clinical pharmacy service Timing of discharge plan: within 48 hours of admission to hospital Education: patient counselling to explain changes to medication Implementation of the discharge plan: daily contact with the patient to explain changes to treatement, medication history, personalised medication record, discharge letter outlining drug history and changes to medication during hospital and variances to discharge prescription. This was faxed to GP and community pharmacist. Personalised medicine card, discharge counselling, labelling of dispensed medications under the same headings for follow‐up. | A hospital based community liaison pharmacist to improve the management of medicines and communication between secondary and primary care during transition from secondary to primary care. | Medicines help line | Standard clinical pharmacy service that did not include discharge counselling |
| Bonnetti 2018 | Discharge planning lead: pharmacist‐led medication counselling Timing of discharge plan: recruited when admitted to hospital, review of discharge medications Education: verbal counseling was delivered by the pharmacists to patients or their caregivers, which included explanations about the indications, benefits, therapeutic targets, doses, dosing schedule, routes, storage, length of therapy, refill pharmacy, and possible ADEs of each prescribed drug. Implementation of the discharge plan: All pharmacist interventions followed a structured format. | A pharmacist led review of medicines to improve communication about medicines during transition from hospital. | Patients were contacted by telephone three and 15 days post‐discharge to reinforce the previous counseling session. | Standard care from pharmacists and other healthcare providers |
| Cajanding 2017 | Discharge planning lead: cardiovascular nurse practitioner led structured discharge plan Timing of patient involvement with the discharge plan: the second day of a hospital admission Education: individualized lecture type discussion, provision of feedback, integrative problem solving, goal setting, and action planning at 3 consecutive daily sessions lasting between 30 to 45 minutes Implementation of the discharge plan: a structured programme based from the guidelines set by the American Heart Association, the National Heart Foundation of Australia, and the Philippine Heart Association. | A nurse led structured discharge programme to improve the quality of care and support the transition from hospital to home | Telephone at 3 and 15 days for the intervention group | Usual care based on the Philippine Heart Association clinical practice guidelines |
| Eggink 2010 | Discharge planning lead: clinical pharmicist Timing of patient involvement with the discharge plan: at discharge Education: none Implementation of the discharge plan: verbal and written information about (side) effects of, and changes in, their in hospital drug therapy from a clinical pharmacist upon hospital discharge and the discharge medication list was faxed to the community pharmacist, a copy was provide to the patient to give to the GP. | A multifaceted clinical pharmacist discharge service on the number of medications discrepancies after discharge, recruited participants had 5 + medicines prescribed | Not reported | Usual care |
| Evans 1993 | Discharge planning lead: not clear Timing of patient involvement with the discharge plan: recruited patients screened at admission for risk of adverse hospital outcome and to minimise inappropriate referrals to discharge planning; discharge planning implemented on day 3 of hospital admission Education: not reported Implementation of the discharge plan: referred to a social worker, assessment of support systems, living situation, finances and areas of need. Plans were implemented with measurable goals. | General discharge plan | Not reported | Could be referred for discharge planning, usually on day 9 of admission |
| Farris 2014 | Discharge planning lead: pharmacist case manager Timing of patient involvement with the discharge plan: day 2 or 3 of admission Education: medication counselling to improve medication adherence, every 2 to 3 days, and discharge counselling Implementation of the discharge plan: a discharge medication list and counselling on goals of treatment, medication and barriers to adherence. Primary care provider and community pharmacist received a copy of the discharge plan within 24 hours of discharge and usually within 6 hours, it included the discharge medication list, plans for dosage adjustments and monitoring, recommendations for preventing adverse drug events, with patient specific concerns such as adherence or cost issues highlighted. | To improve medication related outcomes during transitions of care | Telephone call 3 to 5 days post‐discharge | Usual care was medication reconciliation at admission according to hospital policy, nurse discharge counseling and a discharge medication list for patients. The usual care discharge summary was transcribed and received in the mail by the primary |
| Gillespie 2009 | Discharge planning lead: clinical pharmicists Timing of involvement with the discharge plan: at admission Education: education provided during the hospital admission, a review of medicines and discharge counselling Implementation of discharge plan: medicine review, patient provided with a copy of the discharge letter. The pharmacist provided a comprehensive account of all changes in drug therapy during the hospital stay, including the rationale behind medication decisions, monitoring needs, and expected therapeutic goals. Drug related problems were listed with suggested actions. The physician responsible for the patient on the ward was required to approve the contents of the pharmacist’s discharge letter before it was sent to the patient’s general practitioner with the original discharge letter. The pharmacists’ discharge letters were not given to the patients. | To reduce drug related problems, increase patient safety and reduce use of hospital care in people aged 80 years and older | Telephone call 2 months post‐discharge to assess the management of medicines | Standard care from nurse or physician, pharmacist not involved |
| Goldman 2014 | Discharge planning lead: registered nurse, included native Spanish and Chinese speakers Timing of involvement with the discharge plan: patients who had been admitted in the previous 24 hours were seen by the discharge planning registered nurse Education: disease‐specific patient education that included symptom recognition, medication reconciliation and strategies to navigate the health system. Motivational interviewing techniques and coaching to promote patient engagement. A study RN supplemented verbal instructions with language‐concordant written materials (30). A study RN reinforced teaching using the “teach‐back” method to ensure comprehension (31) Implementation of discharge plan: the discharge planning study registered nurse met with the patient and contacted the patients’ primary care providers to supply the inpatient physicians’ contact information. | A discharge planning nurse led intervention to facilitate the transition from hospital to home | Study nurse practitioners visited patients within 24 hours of discharge, and called patients on days 1 to 3 and 6 to 10 after discharge. | The bedside RN's review of the discharge instructions, received by all patients. If requested by the medical team, the hospital pharmacy provided a 10 day medication supply and a social worker assisted with discharge. The admitting team was responsible for liaising with the patients' PC |
| Harrison 2002 | Discharge planning lead: nurse led Timing of involvement with the discharge plan: within 24 hours of Education: a structured evidence based protocol for counselling and education to support heart failure self‐management Implementation of discharge plan: comprehensive discharge plan, hospital and community nurse liaison, standard discharge planning + a comprehensive program that added support to improve the transfer from hospital to home. Hospital and community nurses met to focus on the ‘outreach’ from the hospital and ‘in‐reach’ from the community during the transition. An inter‐sectoral continuity of care framework was used to identify gaps to specifically address 3 major aspects of a hospital‐to‐home transition: (1) supportive care for self‐management; (2) linkages between hospital and home nurses and patients; and (3) the balance of care between the patient and family and professional providers | A nurse led discharge plan to improve the transition between hospital settings. | Telephone call within 24 hours of discharge | Usual home care visits, available to intervention group |
| Hendriksen 1990 | Discharge planning lead: project nurse Timing of involvement with the discharge plan: at the time of admission Education: health condition and discharge arrangements Implementation of the discharge plan: patients had daily contact with the project nurse who discussed their illness with them and discharge arrangements; liaison between hospital and primary care staff. | A co‐ordinated transfer from hospital to home for older people. | Project nurse, a maximum of two visits after discharge | Usual care |
| Jack 2009 | Discharge planning lead: nurse discharge advocate (DA) Timing of involvement with the discharge plan: Education: the DA used scripts from the training manual to review the contents of an after hospital care plan with the patient. Implementation of the discharge plan: with information collected from the hospital team and the participant, the DA created the after‐hospital care plan (AHCP), which contained medical provider contact information, dates for appointments and tests, an appointment calendar, a colour‐coded medication schedule, a list of tests with pending results at discharge, an illustrated description of the discharge diagnosis, and information about what to do if a problem arises. Information for the AHCP was manually entered into a Microsoft Word template, printed, and spiral‐bound to produce an individualised, colour booklet. On the day of discharge the AHCP and discharge summary were faxed to the primary care provider. | Reengineered hospital discharge to minimize hospital utilisation after discharge. | A clinical pharmacist telephoned the participants 2‐4 days after the index discharge to reinforce the discharge plan by using a scripted interview. The pharmacist had access to the AHCP and hospital discharge summary and, over several days, made at least 3 attempts to reach each participant. The pharmacist asked participants to bring their medications to the telephone to review them and address medication‐related problems; the pharmacist communicated these issues to the PCP or DA | Usual care. |
| Kennedy 1987 | Discharge planning lead: gerontology clinical nurse specialist (GCNS) Timing of involvement with the discharge plan: during the hospital admission Education: focused on explaining and clarifying the discharge plan Implementation of the discharge plan: a comprehensive discharge planning protocol (CDPP) was developed for use by the Gerontological Clinical Nurse Specialist (GCNS). Components of the assessment included: health status, orientation level, knowledge and perception of health status, resource use pattern, functional status, skill level, motivation level, and sociodemographic data. The patient's level of dependency was measured using the Long‐Term Care Information System (LTCIS). The GCNS met with the patient and family, physician, and other health care providers to identify resources and support networks for the patient postdischarge. A summary of the assessment information and potential care needs were entered in the progress notes of the patient's chart.The GCNS assisted in the coordination of services. | A comprehensive discharge planning protocol to improve the health delivered to older people in hospital. | One follow‐up visit to assess the arrangements and care delivered. | Discharge arranged by the primary nurse. |
| Kripalani 2012 | Discharge planning lead: a pharmacist TIming of patient involvement with the discharge plan: at enrolment to the study during a patients admission to hospital Education: one or two counselling sessions to the patient by the pharmacist, that accounted for the patient's health literacy and aimed to support adherence and minimize adverse effects. Pharmacists used 'teach‐back' to confirm understanding. Implementation of the discharge plan: pharmacist assisted medication reconciliation, tailored inpatient counselling, provision of low‐literacy adherence aids. The pharmacists communicated with the treating physicians to resolve any clinically relevant, unintentional medication discrepancies. | A tailored intervention to reduce medication errors at and after hospital discharge. | Telephone follow‐up after discharge by a research coordinator, follow‐up call by a pharmacist to address any issues in collaboration with the treating inpatient and outpatient physicians. | Medicine reconciliation and discharge counselling |
| Lainscak 2013 | Discharge planning lead: a discharge co‐ordinator Timing of patient involvement with the discharge plan: within 48 hours of admission to hospital Education: yes Implementation of the discharge plan: the discharge coordinator assessed the patient situation and home care needs to identify any problems and specific needs. Patients and caregivers were actively involved in the discharge planning process, which was communicated and discussed with community care/home care nurse, general practitioner, social care worker, physiotherapist, and other providers of home services as appropriate to provide continuity of care and care coordination across different levels of health care. | To coordinate discharge from hospital to post‐discharge care to reduce hospitalizations. | Discharge coordinator called the patient 48 hours after discharge to check adjustment to home environment and additional needs, phone calls continued up to 7 to 10 days after discharge when a home visit was scheduled. | Usual care, routine patient education with written and verbal information about COPD, supervise inhaler use, respiratory physiotherapy as indicated, and disease related communication between medical staff with patients and their caregivers |
| Laramee 2003 | Discharge planning lead: heart failure nurse case manager Timing of patient involvement with the discharge plan: during admission Education: a 15 page booked on heart failure to support self‐management. Individualised and family education. Implementation of the discharge plan: early discharge planning and coordination of care; facilitated communication between the hospital team and the patient, involved the patient and family in developing a care plan; review and monitoring of medicines and appropriate recommendations. | Hospital based nurse led case management to co‐ordinate care and reduce hospital utilization. | 12 weeks of telephone follow‐up | Usual care |
| Legrain 2011 | Discharge planning lead: a dedicated geriatrician Timing of patient involvement with the discharge plan: during admission Education: education on self‐management of disease Implementation of the discharge plan: comprehensive chronic medication review according to geriatric prescribing principles, and detailed transition‐of care‐communication with outpatient health professionals. | To co‐ordinate a patient centred mult‐modal comprehensive discharge plan for older people to reduce preventable readmission, depression and protein‐energy malnutrition. | Not reported | Usual care in an acute geriatrician unit |
| Lin 2009 | Discharge planning lead: nurse led Timing of patient involvement with the discharge plan: during the hospital admission Education: not reported Implementation of the discharge plan: structured assessment of discharge planning needs, systematic individualised nursing instruction based on the patient’s individual needs, monitoring services and coordinated resources and arranging of referral placements for each patient. | To improve discharge planning to meet care needs after discharge for older people admitted to hospital with a hip fracture. | Two home visits post‐discharge to provide support and consultation | Unstructured discharge instructions without following a standardised procedure |
| Lindpainter 2013 | Discharge planning lead: nurse Timing of patient involvement with the discharge plan: during admission Education: yes Implementation of the discharge plan: included discharge diagnoses, medication, and plans for follow‐up and home care sent on the day of discharge by to the primary care physician and the local visiting nurse organization. This discharge fax supplemented the hospital discharge summary generated as usual by the staff physician in both the intervention and control groups. | To co‐ordinate care to reduce adverse events and cost | Telephone access via a pager and home visit if required | Standard discharge fax to primary care |
| Lisby 2019 | Discharge planning lead: nurse Timing of patient involvement with the discharge plan: Education: included assessment of patients' understanding of their discharge recommendations that included medicines Implementation of the discharge plan: an assessment of the patient’s overall situation and requirement for additional healthcare and help, a review of medicines, their comprehension of discharge recommendations, a simple discharge letter targeting the individual patient’s health literacy and a follow‐up telephone call. | To co‐ordinate care to increase post‐discharge safety and reduce readmissions. | Two week post‐discharge telephone call | Standard discharge letter provided to the primary care physician, the patient sometimes received a copy. |
| Moher 1992 | Discharge planning lead: a nurse Timing of patient involvement with the discharge plan: shortly after admission to clinical unit. Education: not reported Implementation of the discharge plan: by a nurse co‐ordinator. | To co‐ordinate and facilitate a discharge plan, tests and procedures, liaise with members of the clinical team and to collect and collate patient information. | Not included | Standard care |
| Naji 1999 | Discharge planning lead: Psychiatrist Time of patient involvement with the discharge plan: ‐
Education: ‐ Implementation of the discharge plan: psychiatrist telephoned GP to discuss patient and make an appointment for the patient to see the GP within 1 week following discharge. A copy of the discharge summary was given to the patient to hand‐deliver to the GP and a copy was posted to the GP. | To optimise communication between secondary and primary care at the time of discharge. | Not included | A standard discharge summary |
| Naughton 1994 | Discharge planning lead: nurse Timing of discharge plan: at admission Education: yes Implementation of discharge plan: implemented at the time of admission; team meetings with the GEM and nurse specialist and physical therapist took place twice a week to discuss patients' medical condition, living situation, family and social supports, and patient and family's understanding of the patient's condition. The social worker was responsible for identifying and co‐ordinating community resources and ensuring the post‐discharge care was in place at the time of discharge and 2 weeks later. The nurse specialist co‐ordinated the transfer to home healthcare. Patients who did not have a primary care provider received outpatient care at the hospital. | To build on geriatric management through a care plan that included co‐ordination of post‐discharge care. | Routine follow‐up that was not part of the discharge plan | Standard care |
| Naylor 1994 | Discharge planning lead: nurse Timing of discharge plan: at admission Education: yes Implementation of discharge plan: 1) comprehensive initial and ongoing assessment of the discharge planning needs of the elderly patient and his or her caregiver; 2) development of a discharge plan in collaboration with the patient, caregiver, physician, primary nurse, and other members of the health care team; 3) validation of patient and caregiver education; 4) coordination of the discharge plan throughout the patient's hospitalization and through 2 weeks after discharge; 5) interdisciplinary communication regarding discharge status; and 6) ongoing evaluation of the effectiveness of the discharge plan. | Timely discharge and facilitate post‐discharge care. | Telephone advise was available for up to two weeks after discharge and the nurse initiated two telephone calls during the first 2 weeks after discharge. | Routine discharge plan that was used for all patients |
| Nazareth 2001 | Discharge planning lead: hospital and community pharmacists offered an integrated discharge plan. Timing of discharge plan: not clear. Education: the hospital pharmacist provided patients with information on their medicines and liaised with their carers and community professionals when appropriate, counselled patients and their caregivers on the purpose of the medicines, doses and how to dispose of excess medicines and provided carers and health professionals with a copy of the discharge plan. Implementation of discharge plan: Medication review and counselling, the hospital pharmacist assessed the patient's medication and the ability of the patient to manage their medication, provided medicine aids such as large print and special labels. | Co‐ordination by hospital and community pharmacists to improve care of older people who are prescribed four or more drugs and optimise communication between primary and secondary care professionals | A pharmacist visited the patient at home two weeks after discharge from hospital to review medicines. | Standard discharge letter with diagnosis, investigations and medication, this did not include a review of medicines or a post‐discharge follow‐up visit. |
| Nguyen 2018 | Discharge planning lead: hospital pharmacist TIming of discharge plan: one week before discharge Education: advise on their condition (acute coronary syndrome), risk factors, prevention; experience of medicines, medication aids, teaching back and correcting misunderstandings. Implementation of the discharge plan: Medication review and counselling, a multi‐faceted intervention of two counselling sessions to assess patients knowledge of their condition (acute coronary syndrome). | A multi‐faceted intervention to enhance medication adherence, and reduce mortality and hospital readmission | Two weeks after discharge a 30 minute telephone call by a pharmacist to assess general and medication issues, provide tailored advice, teaching back and correcting misunderstanding | Standard care |
| Parfrey 1994 | Discharge planning lead: member of the multi‐disciplinary team Timing of discharge plan: at admission Education: Implementaiton of the discharge plan: a 1‐page, 65‐item questionnaire was used to identify patients for early discharge planning. | Early identification of patients for dicharge planning to reduce hospital length of stay | No | Standard discharge arrangements |
| Preen 2005 | Discharge planning lead: multidisciplinary discharge care planning with primary care providers Timing of discharge plan: 24‐48 hours prior to discharge Education: patients were involved in identifying problems and goals Implementation of the discharge plan: problems and goals identified with the patient and carer, community service providers were identified who met patient needs and who were accessible.The discharge plan was faxed to the GP and all service providers identified on the care plan. | A discharge care planning model to provide quality discharge arrangements and facilitate continuity of care and communication between the hospital and primary care physician | GP scheduled a consultation (within 7 d postdischarge) for patient review | Standard care that included a discharge summary provide to the patients and GP |
| Rich 1993 | Discharge planning lead: cardiovascular specialist nurse Timing of discharge plan: early in the hospital admission Education: education about heart failure, treatment plan, diet and medicines using a 5 page guide Implementation of the discharge plan: review of medicines with recommendations to support compliance and reduce adverse effects, early discharge planning, review by social worker and home care team. The discharge plan was sent to the home care division. | To facilitate discharge planning and ease the transition from hospital to home | Home care visited the patient at home within 48 hours of discharge and two more times during the first week, and then at regular intervals. | Standard care, without the education materials or formal medication review |
| Rich 1995 | Discharge planning lead: cardiovascular specialist nurse Timing of discharge plan: early in the hospital admission Education: education about heart failure, treatment plan, diet and medicines using a 5 page guide Implementation of the discharge plan: review of medicines with recommendations to support compliance and reduce adverse effects, early discharge planning, review by social worker and home care team. The discharge plan was sent to the home care division. | Reduce the risk of readmission | Home care visited the patient at home within 48 hours of discharge and two more times during the first week, and then at regular intervals. | Standard care, without the education materials or formal medication review |
| Shaw 2000 | Discharge planning lead: hospital pharmacist Timing of discharge plan: during hospital admission Education: patient knowledge of illness and medicines was assessed by a questionnaire, and information was provided Implementation of the discharge plan: Medication review and counselling, a checklist was used to identify needs, details of the treatment plan were provided and provided to the patient's community pharmacist | To identify medication problems experienced by patients | Domiciliary visits at 1, 4 and 12 weeks to assess knowledge and continuing care needs. | Standard care |
| Sulch 2000 | Discharge planning lead: senior nurse with multi‐disciplinary team Timing of the discharge plan: day 5 to 6 of hospital admission Education: patient and carer education about the care plan and rehabilitation process, medicines, prognosis and related health problems Implementation of the discharge plan: discharge plan was revised during the hospital stay, the plan included discharge options and a date of discharge | An integrated care pathway to reduce hospital length of stay in people with a stroke and having specialist rehabilitation | Routine follow‐up that was not part of the discharge plan | Standard multi‐disciplinary care |
| Weinberger 1996 | Discharge planning lead: primary care nurse Timing of discharge plan: three days before discharge Education: patients were provided with educational material. Implementation of the discharge plan: assessment of post‐discharge needs, listed medical problems, assigned the patient to a primary care physician. | Targetted people with diabetes, chronic obstructive pulmonary disease or heart failure who were at risk of readmission. Aimed to reduce readmission by strengthening the planning of post‐discharge care | Primary nurse telephoned the patient 2 days after discharge, patient given an appointment to attend the primary care clinic within one week of discharge. | Standard care, did not have access to primary care nurse and did not receive supplemental education or assessment of needs beyond usual care. |
