Strategies to Improve Emergency Transitions From Long-Term Care Facilities: A Scoping Review

Abstract Background and Objectives Older adults residing in residential aged care facilities (RACFs) often experience substandard transitions to emergency departments (EDs) through rationed and delayed ED care. We aimed to identify research describing interventions to improve transitions from RACFs to EDs. Research Design and Methods In our scoping review, we included English language articles that (a) examined an intervention to improve transitions from RACF to EDs; and (b) focused on older adults (≥65 years). We employed content analysis. Dy et al.’s Care Transitions Framework was used to assess the contextualization of interventions and measurement of implementation success. Results Interventions in 28 studies included geriatric assessment or outreach services (n = 7), standardized documentation forms (n = 6), models of care to improve transitions from RACFs to EDs (n = 6), telehealth services (n = 3), nurse-led care coordination programs (n = 2), acute-care geriatric departments (n = 2), an extended paramedicine program (n = 1), and a web-based referral system (n = 1). Many studies (n = 17) did not define what “improvement” entailed and instead assessed documentation strategies and distal outcomes (e.g., hospital admission rates, length of stay). Few authors reported how they contextualized interventions to align with care environments and/or evaluated implementation success. Few studies included clinician perspectives and no study examined resident- or family/friend caregiver-reported outcomes. Discussion and Implications Mixed or nonsignificant results prevent us from recommending (or discouraging) any interventions. Given the complexity of these transitions and the need to create sustainable improvement strategies, future research should describe strategies used to embed innovations in care contexts and to measure both implementation and intervention success.


Background and Objectives
As life expectancy increases, older persons (≥65 years) are more likely to live with multiple comorbid conditions often combined with functional and/or cognitive impairments (Sternberg et al., 2011).Older Canadians comprise about 20 to 40% of emergency department (ED) visits and their ED use rates have more than doubled in the last decade (Canadian Institute for Health Information, 2023).Transitions for older persons from residential aged care facilities (RACFs) to the ED are challenging as many of these individuals have complex needs are grappling with personal end-of-life decisions, and often lack the capacity to self-advocate their wishes (Aaltonen et al., 2014;Adamczyk et al., 2018;Cummings et al., 2012Cummings et al., , 2020;;Orth et al., 2021;Page et al., 2010).Older adults' transitions from RACFs to the ED can result in poor outcomes related to functional decline, dehydration, infections, confusion, and loss of personal assistive devices (Cline, 2016;Cummings et al., 2020;Rantz et al., 2015;Trahan et al., 2016).For decades researchers have identified various substandard RACF to ED transitions for the frailest of our populations and have expressed an urgent need to improve these transitions (Adamczyk et al., 2018;Cummings et al., 2020;Tate et al., 2021Tate et al., , 2022Tate et al., , 2023)).Challenges during transitions from RACFs to the ED include but are not limited to (a) difficulty coordinating care across various healthcare professionals from multiple care settings/cultures, (b) nonstandardized and insufficient documentation practices (Bruce & Suserud, 2005;Coleman et al., 2003;Morphet et al., 2014;Tate et al., 2023), (c) communication challenges that are exacerbated when older persons cannot clearly express their care needs (Page et al., 2010;Zimmerman et al., 2007), (d) atypical presentations when older people experience serious 2 The Gerontologist, 2024, Vol. 64, No. 7 changes in health conditions (Armstrong, 2015;Chandra et al., 2015), and (e) ageism through rationing and delayed care (Adamczyk et al., 2018;Grief et al., 2013;Saif-Ur-Rahman et al., 2021;Van Wicklin. 2020).
Existing research on RACF to ED transitions focuses on knowledge creation (e.g., quantifies and presents factors associated with care transitions; Trahan et al., 2016), investigates strategies to prevent transitions from occurring (Cetin-Sahin et al., 2023;Grant et al., 2020), seeks to improve limited components of care (e.g., medication reconciliation; Chhabra et al., 2012;Grant et al., 2020), or describes staff perspectives and experiences of transitions (Chhabra et al., 2012;Gettel et al., 2020;LaMantia et al., 2016).Although most reviews examine traditional measures of intervention effectiveness (e.g., reduction in transfer rates), few authors have examined implementation processes simultaneously with the aforementioned measures (Proctor et al., 2011).
To the best of our knowledge, no authors have summarized the interventions tested to improve the RACF to ED care transition regardless of study design.The purpose of this review is to identify and describe the research examining interventions to improve transitions during RACF-ED transitions.We accepted study authors' definitions or descriptions of improvement, or included studies in which no explicit definition was provided but where authors articulated an issue that occurred during these transitions that they aimed to address.We maintained this broad description of improvement to identify the various ways in which it is described or applied in the literature.Our objectives were to: 1. identify and describe interventions/strategies to improve transitions from RACF to the ED; 2. describe implementation strategies employed on interventions to improve transitions from RACF to the ED, such as how researchers embedded study interventions into local care contexts; and 3. identify approaches used to assess intervention and implementation effectiveness related to transition from RACF to the ED.
Our study objectives and analyses were guided by the Care Transitions Framework of Dy et al. (2015), which recognizes the complexity of healthcare environments and the need to ensure that interventions are properly embedded into these environments.This framework aligns with arguments put forth by Proctor et al. (2011) and Bowen et al. (2009) that fulsome evaluation of interventions in complex health systems requires diverse strategies that assess both traditional measures of intervention effectiveness (e.g., reduced transfer rates) and implementation success (e.g., stakeholder acceptability, feasibility, fidelity, sustainability of an intervention).In a collective effort to sustain intervention effectiveness in "real-life" settings, common themes across these and related frameworks emphasize the need to ensure that planned interventions are properly embedded into care environments, and that evaluation techniques assess the success of this contextualization along with intervention success.This approach also has value for differentiating poor intervention ideas from promising practices that require better implementation processes (Bauer & Kirchner, 2020).

Research Design and Methods
We employed Levac et al.'s (2010) approach to conducting a scoping review.We used the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses: extension for Scoping Reviews; Supplementary File 1) reporting guidelines (Moher et al., 2009).

Inclusion and Exclusion Criteria
We included literature examining strategies to improve RACF-ED transitions.Detailed inclusion and exclusion criteria are available in Table 1.

Search Strategy
We developed a search strategy with an academic health sciences librarian.Search terms included but were not limited to: "older persons, aged, elder," "transition/transfer/ move," "emergency department/emergency room," and "residential facility/long-term care/nursing home/assisted living."A full search strategy is provided in Supplementary File 2. We searched five electronic databases in September 2022: EBSCOhost CINAHL Plus (1982 to present), Ovid Embase (1988 to present), Ovid MEDLINE (In-Process and other non-indexed citations; 1946 to present), Ovid PsycINFO (1987 to present), SCOPUS (1960 to present).We actively sought gray literature through searching Google Scholar, organizational and government websites, and requesting sources from health-system decision makers on our research team.

Screening Procedures
Records were managed in EndNoteX9© to remove duplicate records.Unique records were exported to Rayyan (Ouzzani et al., 2016) to complete screening.Team members

Criteria Include Exclude
Topic Literature examining an intervention or strategy intended to improve transitions from RACFs (nursing homes/long-term care or supportive living/assisted living facilities) to the ED.We accepted author definitions of improved RACF to ED transitions and the measures they posed as operationalizing these definitions.
Literature examining interventions aimed at only preventing/reducing RACF to ED transitions.Literature on transitions from ED to RACF.Literature on RACF to ED transitions for planned procedures or elective treatment.

Population
Older adults (persons ≥65 years of age).Individuals younger than 65 years.

Design or publication type
Primary research studies, secondary analyses, and gray literature.Excluded published conference abstracts, editorials and systematic reviews.
(KT, IA, JW, MD, FJ, GGC, GH, GVB, JF) independently screened 100 abstracts and met to finalize inclusion and exclusion criteria.Then, each abstract was reviewed independently by two of five team members (KT, IA, JW, SS, RD).We held consensus meetings between paired reviewers to resolve conflicts.If consensus could not be reached, a third team member (KT, TP) reviewed the abstract to make a final decision.We repeated these procedures for full-text screening.

Data Extraction
We adapted a data extraction form, previously used by team members, to include concepts from the Care Transitions Framework (Dy et al., 2015).

Quality Assessments
We conducted quality assessments for all included studies using the Mixed-Methods Appraisal Tool (MMAT) version 2018 (Hong et al., 2018;Souto et al., 2015) but did not exclude studies based on quality.Team members (KT, TP, RD, SS, IA, JW) independently assessed each included study.We held consensus meetings to resolve conflicts.
The MMAT quality appraisal tool consists of two screening questions and five questions on methodological quality criteria for each type of research design.Each criterion has three response options: Yes (criterion met: score 1), No (criterion not met: score 0), Can't tell (not enough information in the paper to judge if the criterion is met or not: score 0).We have provided individual study scores for each item, as is recommended, as well as individual study total scores in Supplementary File 2. We did not score all items of two studies based on lack of clarity of research question and relevance of data collected, as the remaining scores about study quality are based on positive or clear responses to these screening questions.Total quality scores for each study are provided in the study characteristics table (Table  2).Total quality score ranges from 20% (if only one criterion is met) to 100% (if all criteria are met).The study is considered of poor quality if it scores 20%, medium quality if it scores 40% or 60%, and high quality if it scores 80% or 100%.

Data Analysis
We employed numerical summary and qualitative content analysis to categorize study characteristics and substantive findings.Intervention categories were grouped by team members during data extraction based on similarities and differences in the author descriptions, nomenclature used, and the major intervention components.Findings were tabulated within these categories.We held team analysis meetings until we reached a consensus on the findings.

Results
Once duplicates were removed, we screened 3,576 abstracts.Data were extracted from 28 articles after screening 209 fulltext articles (see Figure 1).

Study Characteristics
Studies were conducted in Australia (n = 12), the United States (n = 9), the United Kingdom (n = 2), Canada (n = 2), Spain (n = 1), Taiwan (n = 1), and Israel (n = 1).Of the 28 included studies, descriptions of improved transition were explicitly reported in 4 and were implicit either in the study's aims, discussion, or conclusion in 7 (noted in the table as implicit), whereas in 17, they were not reported.Although our search criteria included a range of RACFs, no authors assessed care transitions solely from other congregate housing settings (e.g., assisted living).The most commonly reported study designs were retrospective cohort (n = 8), pre-post-test designs (n = 6), and prospective cohort (n = 2).Other designs were represented in only single studies (e.g., interrupted time series, nonrandomized step wedge, case study), and in four cases, no clear design was reported.Study characteristics are presented in Table 2.
Descriptions of improved transitions were not reported in 11 of 24 studies (Supplementary File 3).In 7 of these 11 studies, some understandings of improved definitions were suggested (labeled as "implicit" in Supplementary File 3) in the background or discussion of included papers.Only four studies included explicit descriptions of improved transitions (e.g., documentation of essential data provided to the ED with the use of a one-page, standard RACF-to-ED transfer form; Terrell et al., 2005).

Quality Assessment Findings
Quality assessment scores (presented in Table 2 and Supplementary File 2) indicated that many studies included large, representative samples and had relatively high scores (80-100).Study weaknesses included incomplete and/or lower-quality data and a lack of adjustment for confounding factors.

Study Findings by Intervention Categories
We identified the following intervention categories (Table 3): geriatric assessment teams or outreach services (n = 7), standardized checklists or documentation forms (n = 6), models of care to reduce or improve transitions from RACF to the ED (n = 6), telehealth services (n = 3), nurse-led care coordination programs (n = 2), use of geriatric acute-care departments to bypass traditional ED services (n = 2), an extended care paramedicine program (n = 1), and a web-based referral system (n = 1).Intervention characteristics and findings are presented in Table 2. Next, we highlight key findings across types of interventions.

Geriatric assessment teams or outreach services
Seven studies examined how geriatric-focused assessment teams or outreach services resulted in improved and/or reduced long-term care (LTC)-ED transitions (Table 3).These teams were comprised primarily of geriatricians and specialized nurse practitioners, and to a lesser extent other allied health professionals.Although most interventions aimed to primarily reduce these transitions, the authors also examined the improved outcomes for transitions that did occur.The  (Ling et al., 2018), decreased odds of hospital readmissions (Hullick et al., 2021), increased odds of hospital admissions (Hullick et al., 2016), and no significant effect on hospital admissions (Cavalieri et al., 1993).Two studies reported cost savings by using fewer services, consults, and the use of skilled nursing staff rather than a physician-only approach (Burl et al., 1998;Chan et al., 2018).The authors of one study presented cost savings as evidence of implementation effectiveness (Burl et al., 1998).The authors of another study concluded that their intervention was safe and sustainable based on only one treatment complication event in 2 years (Chan et al., 2018).
Although no authors discussed if or how they explicitly and proactively contextualized the intervention they examined, several (n = 6) discussed contextual factors that may have influenced study results.Examples include seasonal variation in ED transfers (Chan et al., 2018;Ling et al., 2018); different understandings of RACF legislative guidelines (Chhabra et al., 2012); differences in staff mix, availability, and expertise (Burl et al., 1998;Chan et al., 2018); the ability to provide rapid responses in RACF (Chan et al., 2018); availability of ambulance services, awareness of geriatric assessment teams or services (Chan et al., 2018;Ling et al., 2018); and factors related to leadership, a culture that supports quality improvement and a community of practice (Hullick et al., 2016(Hullick et al., , 2021)).

Standardized checklists or documentation forms
Authors in six studies assessed how standardized documentation forms improved RACF to ED transfers (see Table 3).Two of these studies reported no statistically significant findings related to case resolution time, admission and discharge status, length of hospital stays, and 30-day readmission rates (Dalawari et al., 2011;Tsai & Tsai, 2017).The authors of a third study reported that healthcare professionals felt that the form was useful and improved handover processes, and was also a sustainable strategy to improve care transitions (Belfrage et al., 2009).
The authors of three studies evaluated healthcare professionals' perspectives on whether using standardized documentation forms improved their understanding of patient needs and ability to care for patients (Madden et al., 1998), and also assessed form uptake (Belfrage et al., 2009;McLane et al., 2022) and item completion (McLane et al., 2022;Terrell et al., 2005).Belfrage et al. (2009) reported that form uptake was high (89%) for eligible cases, whereas McLane et al. (2022) reported lower form uptake (43%; McLane et al., 2022).Item completion improved or was perceived to have improved (by RACF, emergency medical services [EMS], and ED staff) in both studies (McLane et al., 2022;Terrell et al., 2005).
Generally, the authors did not explicitly describe how they embedded the form content and documentation process to meet the needs of study participants (as in these studies, the authors led form development or adaptation).McLane et al. (2022) reported that form content was based on findings from earlier research identifying issues that residents, family members, and staff reported during the transition process.The authors discuss how contextual factors influenced intervention implementation and success.Key factors included early engagement with relevant stakeholders (Madden et al., 1998); complexity and layout of the form (Dalawari et al., 2011); recognizing that participants had limited time in emergency situations (Dalawari et al., 2011;McLane et al., 2022); and ensuring that processes aligned with healthcare professional values about formal record keeping (McLane et al., 2022).The noted challenges included the use of multiple (existing and new) forms (McLane et al., 2022), lack of a single point of leadership and oversight during a transition, and staff mix and turnover (Dalawari et al., 2011;Tsai & Tsai, 2017).

Models or programs of care
Five studies examined multiple interventions presented as a model of care developed to improve RACF to ED transitions.These approaches included various services (e.g., medical advisory meetings, after-hours telehealth, homecare services; Lisk et al., 2012), tools (e.g., INTERACT, a quality improvement program that includes educational and clinical tools to improve care for residents in RACFs; Pathway Health, 2023), and improved access to healthcare professionals to support the assessment and overall management of care for RACF residents.
Findings from this type of intervention were largely positive.Monthly hospitalizations significantly decreased by 62.4% postintervention in one study (Stadler et al., 2019) and ED admissions were significantly lower in another (Lisk et al., 2012;Lloyd et al., 2019).Lisk et al. (2012) found that their suite of services significantly reduced the length of hospital stay.The authors examining the INTERACT program (Kane et al., 2017) found no significant reductions in hospitalizations.The authors from three studies reported that participants provided positive feedback about the intervention (Conway et al., 2015;Kane et al., 2017;Lisk et al., 2012).
Examples of how contextual factors influenced their study results include funding models and how this influenced researchers' ability to provide training and additional resources (Conway et al., 2015;Lisk et al., 2012;Lloyd et al., 2019), and benefits of integrating the intervention into standard and/or usual care practices (Lloyd et al., 2019;Stadler et al., 2019).Kane et al. (2017) posit that intervention effectiveness was influenced by facility for-profit status, quality performance standings on national websites, and staff motivation to reduce hospitalizations and readmissions based on value-based care initiatives (Kane et al., 2017).

Telehealth services
Results pertaining to telehealth services were mixed.The authors in one study reported significantly lower odds of hospital admissions (Joseph et al., 2020).Hullick et al. (2022) reported no significant reduction in admissions using telehealth.Conway et al. (2015) reported that the use of telehealth decreased total inpatient hospital days and concluded that this intervention gave RACF staff more confidence in their ability to manage resident care (Conway, Higgins, et al., 2015).The authors reported that contextual factors influencing intervention implementation and success included the coronavirus disease 2019 (COVID-19) pandemic (Joseph et al., 2020), differences in staff mix and scope of practice, RACF policies, lack of primary care medical providers on site, and limited ability of specialists to fulfill medication orders and re-initiate consultation (Conway et al., 2015;Joseph et al., 2020).

Nurse-led care coordination
The authors in two studies investigating nurse-led care coordination interventions reported reductions in ward admissions and end-of-life inpatient episodes (Marsden et al., 2018;Shrapnel et al., 2019), and enhanced cost effectiveness in one study (Shrapnel et al., 2019).Marsden et al. (2018) adapted their intervention based on participant feedback, specifically by developing brochures and a communication board, conducting staff education sessions, and providing bright t-shirts for care team members (Marsden et al., 2018).The authors discussed key contextual factors influencing intervention effectiveness and implementation, including supports provided for the intervention, the commitment of key staff, staff mix and nurse practitioner ability to practice to full scope, the use of existing care services, buy-in from stakeholders, and age of the residents presenting to the ED (Marsden et al., 2018;Shrapnel et al., 2019).
Generally, remaining interventions (i.e., extended paramedicine program, web-based referral system, acute geriatric departments) reduced the number of residents transferred to acute care, but did not impact other outcomes such as the extent or duration of functional decline during hospital stay (Aizen et al., 2001).In their assessment of the extended care paramedicine program, Jensen et al. (2016) reported no significant differences in EMS response and scene time, ED length of stay, and hospital admission and relapse.Nonsignificant increases in scene times were reported to be influenced by the time it took paramedics to develop a care plan and to consult with the physician/ED while concurrently communicating with families.Most ED physicians were completely satisfied with a web-based referral system to help guide RACF to ED transitions (Zamora et al., 2012).The authors discussed the importance of technical support, access to computers, and staff computer literacy to ensure successful intervention implementation.

Discussion and Implications
Our study augments existing systematic reviews by (a) expanding on the breadth of research designs examined, (b) employing a theoretical framework, and (c) demonstrating the (limited) extent to which the researchers currently have tailored their interventions to care settings and/or assessed implementation effectiveness.This research is unique and advances knowledge by focusing on strategies that have been used to improve transitions from RACF to EDs.From our examination and critique of how improvement is described in the literature, we illustrate the need for researchers to clearly articulate the concept of "improvement"; to explain in  ease of identifying resident information was improved with form use (significant at <.05) except for those related to current medication list, medical history and laboratory tests/xrays.Long-term care (LTC) survey results on ease of use were nonsignificant.Some participants reported the form as stressful, redundant, time-consuming to complete, and being frustrated at sharing documentation across care settings, whereas some reported that it was easy to use and was comprehensive.Some participants prioritized form completion over direct patient care.Median uptake of forms was 43%.Only 1 form of 100 was completed by all care settings.Of 74 forms in which both pages were accounted for, all LTC portions were completed, 26% of EMS portions were completed and 7% of ED portions were completed  with GP, daily telephone advice, medi-home, end-of-life care, and email alert system To reduce admission, need for medical input for residents was discussed between primary doctor and care home manager, geriatric consultants provided telephone advice, specific nursing care for those awaiting discharge with no need of acute services, and end-of-life care documentation to facilitate expression of residents and caregivers wishes.
Email alert system for transitions, and geriatrician review before discharge and liaison with admitting team and primary doctor were used as approaches to reduce the LOS.Notes: Types of interventions to improve transitions from facility-based care settings to the ED included: geriatric assessment teams or outreach services (n = 7), standardized checklists or documentation forms (n = 6), models of care or suites of tools to reduce or improve transitions from RACF to the ED (n = 6), telehealth services (n = 3), a nurse-led care coordination program (n = 2), use of an acute-care department in a geriatric hospital to bypass traditional ED services (n = 2), an extended care paramedicine program (n = 1), web-based referral system (n = 1).CI = confidence interval; ED = emergency department; IQR = interquartile range; OR = odds ratio.(Armstrong, 2015;Chandra et al., 2015) or ageism that can lead to rationing or delayed care for older adults (Adamczyk et al., 2018).
Given the noted methodological and conceptual gaps in the literature, it is challenging to recommend an intervention that can improve RACF to ED interventions.Although standardized documentation forms are frequently used, there is no consensus on critical information to include in these forms, and no authors have evaluated if these interventions improve the quality or accuracy of documentation content.Inconsistent or insufficient documentation practices occur (Tate et al., 2023) and have been linked to adverse outcomes, underdiagnosing, and inappropriate treatments for older adults during transitions in care (Bruce & Suserud, 2005;Morphet et al., 2014).The authors of a recent systematic review (Gettel et al., 2020) also reported a lack of measures to assess critical events during care transitions such as medication errors, duplicative diagnostic testing and procedures, and adverse events.Other literature suggests that documentation interventions should be integrated into electronic recordkeeping and be accompanied with cross-setting education that supports a geriatric focus (McLane et al., 2022;Tate et al., 2023).We recommend that researchers examine the quality and consistency of documentation (vs measuring form uptake and item completion) using more robust, mixed-method approaches.Furthermore, the perspectives of residents and informal caregivers need to be considered to help ensure that essential information (e.g., whether their assistive devices are transported across care settings) is captured (Cummings et al., 2020;McLane et al., 2022).
Geriatric assessments/outreach services and various programs of care were examined in many studies.However, the primary focus of these interventions has been to reduce transitions from RACF to the ED.Results from these studies were mixed and focused on distal outcomes (outcomes that occur late in the transition process or well after the transition has been completed) such as hospital admissions, length of stay, and readmissions.Interdisciplinary approaches are emerging as promising to help reduce unwarranted RACF to ED transitions (Grant et al., 2020).Intentionally adapting these approaches for improving transitions while using established implementation science and feasibility study methods is warranted (Bowen et al., 2009;Damschroder et al., 2009;Waltz et al., 2019).Last, tele-and digital-health services show promise and have increased in uptake during the COVID-19 pandemic.Guidelines for improving digital or telehealth services for people experiencing mental health challenges (Graham et al., 2020) align with the contextual issues (e.g., digital literacy, lack of technical support, and access to technology) identified as important in this review.Implementation strategies such as conducting needs assessments and ensuring supervision and resources pertaining to software training and integration as outlined in Graham et al.'s review (Grant et al., 2020) could be adopted to improve the implementation of tele-and digital-health services.
Current approaches to intervention development do not reflect the advances made in implementation science-as espoused in the Care Transitions Framework (Dy et al., 2015), the Consolidated Framework for Implementation Research, and the Expert Recommendations for Implementation Change tool-to guide planning and implementation of interventions (Damschroder et al., 2022;Waltz et al., 2019).Collectively these frameworks elucidate key strategies for contextualizing and implementing innovations in complex adaptive systems like an RACF or ED.Their application is one means to ensure that intervention implementation reflects the intended approach and is not impeded by factors such as competing provider priorities, insufficient human resources and/or training, and inadequate attention paid to important change management principles (e.g., appropriate application of plando-study-act cycles as reported by the Institute for Healthcare Improvement, 2023).These principles are requisite to build skill sets and expertise among stakeholders and thus promote innovation, sustainability, and eventual scale (Damschroder et al., 2022;Waltz et al., 2019).They have been used to successfully implement geriatric screening interventions in EDs and to promote age-friendly care in healthcare in multiple regions (Damschroder et al., 2022;Dolansky et al., 2021).Our findings, derived from identified factors in included studies, support that we may improve intervention development through ensuring that (a) designated leaders are available to support and guide care practice changes, (b) existing policies do not impinge on stakeholders' ability to enact intervention plans, and (c) proactive discussions and subsequent action takes place to help ensure that planned care changes align with existing care contexts (e.g., by recognizing the limited time that providers have to make decisions in emergency situations and by providing timely access to experts for education and advice).Given the complexity of care transitions (Aase & Waring, 2020) and the need to measure intervention effectiveness more robustly, we recommend that future research should employ mixed-method strategies to more aptly assess implementation and intervention effectiveness.This twopronged evaluation approach is paramount to differentiate ineffective interventions from potentially promising practices with substandard implementation practices.
Furthermore, researchers are not exploring how care delivery during the transition can be improved by interventions (and instead evaluate distal outcomes), and no study employed any frameworks related to transition care (Aase & Waring, 2020) and/or domains of quality to evaluate care, such as Institute of Medicine's Quality Domains (Agency for Healthcare Research and Quality, 2002; Institute of Medicine (U.S.) Committee on Quality of Health Care in America, 2001).Employing these types of frameworks is needed for developing and applying measures to evaluate the effectiveness of interventions to improve transitions from RACF to the ED across various domains of quality (e.g., safety, person-centeredness, equity; Tate et al., 2022).

Limitations and Strengths
Our findings may be influenced by publication bias.Only articles published in English were included.As strengths, the review was guided by a theoretical and methodological framework and was conducted in collaboration with health-system decision makers from multiple jurisdictions.Our search strategy was developed in consultation with an academic librarian and we searched five comprehensive databases.

Conclusions and Implications
This manuscript identifies conceptual, methodical, and measurement shortcomings in the literature seeking to improve RACF to ED transitions, and provides insight into strategies needed to advance this research area.Mixed or nonsignificant results, combined with these research challenges, prevent us from recommending (or discouraging) any intervention to improve RACF to ED transitions.Conceptual clarity and clear, congruent operationalization of an improved transition is needed.We recommend that future research employ established frameworks to clarify the goals for improving transitional care from the viewpoint of various stakeholders, to engage purposefully with stakeholders (e.g., providers, patients) to ensure that proposed innovations are properly contextualized, and to robustly assess innovation success using a range of designs, intervention, and implementation effectiveness metrics.

Table 1 .
Inclusion and Exclusion Criteria for Literature on Improving Transitions From RACF to EDs

Table 2 .
Characteristics of Included Studies

Table 2 .
Continuedauthors reported mixed results for interventions involving geriatric assessment teams or outreach services.Results ranged from significantly decreased hospital admission rates

Table 3 .
Included Interventions Categorized by Intervention Type

Table 3 .
Continued The overall number of patients who were admitted to the hospital was not different between study periods.In the after period, fewer patients who received care from ECP were admitted compared to those from emergency paramedics.The response and scene times were statistically significantly longer when ECP was involved in the call compared to emergency paramedics in the after phase.Differences were not observed in the length of time EMS crews spent in the EDs in the before or after periods, or in the subgroup analysis of the after period Implementation findings: Not reported

Table 3 .
Continuedgreater detail how interventions designed to achieve this goal are developed and contextualized to align with care environments; and to create more fulsome evaluation platforms that assess the concepts of intervention and implementation effectiveness.In doing so, we can differentiate promising practices that suffer from inadequate implementation strategies from interventions that are less likely to achieve these goals.A lack of conceptual clarity about what constitutes an improved care transition makes interstudy comparisons challenging.Notably, close to half of all included studies (n = 10) were retrospective in nature and may be prone to confounding by indication bias.Half of the included studies (n = 14) focused primarily on reducing potentially avoidable transitions, rather than improving them.Researchers have not examined resident-or caregiver-reported outcomes, few have included healthcare professional perspectives, and none have examined transitions from assisted living environments.Last, no existing interventions designed to improve RACF to ED transitions focus on issues such as addressing atypical presentations of older adults during serious changes in health condition