Objectives:

To summarize recent relevant literature on patient safety practices (PSPs) focused on engaging family caregivers with structured communication during care transitions and assess the effectiveness of these PSPs to improve safety during care transitions. This review provides information for clinicians, health system leaders, and policymakers to better inform approaches to engaging family caregivers with structured communication to improve safety during care transitions.

Methods:

We followed rapid review processes provided by the Agency for Healthcare Research and Quality Evidence-based Practice Center Program. We searched PubMed, Embase, and the Cochrane Library for eligible studies published in 2010 through June 30, 2023, supplemented by targeted gray literature searches and review of reference lists in relevant systematic reviews. We used prespecified inclusion and exclusion criteria to assess relevant studies conducted in the United States that analyzed the effect of structured communication on care transitions with family caregivers. Prespecified clinical and patient-related outcomes included healthcare utilization, symptom exacerbation, quality of life, satisfaction, and unintended harms, among others.

Findings:

We identified 323 unique citations for possible inclusion; we assessed 86 full-text articles for inclusion. We included nine studies on effectiveness (2 randomized controlled trials, 6 pre-post studies, and 1 single-arm study) which assessed PSPs focused on discharge to home, transfers from intensive care units, and transitions from residential care. In residential treatment facility discharges, we found PSPs improved caregiver satisfaction (low strength of evidence [SOE]). We found insufficient evidence of other PSPs on any other included outcomes. Five studies detailed implementation facilitators, and two studies noted specific barriers to PSP implementation. While no studies specifically reported the resources required to implement PSPs, based on study descriptions, we identified four prominent resource considerations: (1) allocated time for pre-implementation intervention development and staff training; (2) designated time to deliver PSPs to family caregivers; (3) technology-based resources; (4) staff-expertise/addition training for designated roles. None of the studies reported rates of unintended harms.

Conclusions:

Clear communication with patients and caregivers during care transitions is important, but there is little evidence on the effectiveness of these PSPs. Included studies showed improvement in caregiver satisfaction, but more high-quality research is needed to assess the effectiveness of PSPs and unintended harms.

1.1. Overview of Engaging Family Caregivers With Structured Communication for Safe Care Transitions

Caregivers are individuals who assist others with social or health needs, supporting others in a number of ways including bathing and eating, providing community and health-related transportation, medication management, ongoing care coordination and communication, and/or managing a chronic condition.^4,5 Family caregivers are informal or unpaid adult caregivers providing support to a family member or friend⁶ and includes relatives, friends, partners, or others who have a close personal relationship with the individual they are supporting.^5,7 As of 2020, approximately 53 million American adults (21.3%) reported being a caregiver with 14.1 million (5.7%) and 41.8 million (16.8%) caring for an individual aged less than 18 years or more than 49 years, respectively.⁶

Care transitions refers to when patients move between healthcare practitioners or settings as their care needs change.⁸ This rapid review focuses on care transitions involving family caregivers either within or between healthcare settings (e.g., intensive care unit to hospital; hospital to skilled nursing facility), or from an inpatient or emergency setting to an outpatient setting where family caregivers are primarily responsible for continuing care for the patient.

Clear communication between healthcare professionals and between caregivers and patients is an important aspect of delivering quality healthcare at points of care transitions⁹ and is a key component of frameworks to improve patient safety during transitional care.^10–12 Patients and caregivers desire and may benefit from better communication at transitions of care.^11,13–15

Structured communication is an approach to improve verbal interactions via use of standardized procedures, tools, or templates, with the goal of facilitating clear and complete sharing of relevant information and better understanding by all parties. Healthcare professionals use structured communication techniques to deliver information between each other and to caregivers and patients. Structured communication differs from unidirectional information sharing with family caregivers, such as discharge instructions and patient education handouts. Structured communication allows for interactions with family caregivers allowing them to express their concerns, while simultaneously allowing clinical providers to assess their understanding of the treatment plan and correct misunderstandings in real time. Further, the structured communication is not necessarily a one-time event; instead the communication protocols can extend beyond the initial care transition through ongoing communication and interaction.

Examples of structured communication tools and approaches include, among others, the Teach-Back Method,^16,17 checklists,¹⁸ the I-PASS tool,^19,20 and computer-assisted programs^21,22 and modules embedded within electronic health records. For discharge to the home, the communication to caregivers can include content such as medication administration, wound care, and the timing of followup appointments. Structured communication approaches help healthcare professionals establish communication processes and instruments to guide a conversation to ensure other individuals (e.g., other healthcare professionals, caregivers, patients) comprehend the next steps in care and know how and when to access additional support from the healthcare system. These approaches may improve direct health and utilization outcomes for patients, but may also impact the experience of post-transitional care for family caregivers who often experience additional stress and burden due to their caregiving responsibilities.

This topic, which was not covered in previous Making Healthcare Safer (MHS) reports, differs in a few ways from the concurrent MHS IV rapid response on Patient and Family Engagement.²³ This rapid review is specific to structured communication related to care transitions. Consequently, it can involve an intervention that only provides information to family caregivers (unlike the rapid response on Patient and Family Engagement, which excluded information-only interventions). Secondly, it only addresses care transitions in multiple healthcare settings, whereas the scope of the rapid response on Patient and Family Engagement included interventions within a single setting. Third, unlike the rapid response, which only included interventions directed at patients and/or family members, this topic includes interventions specifically targeted at family caregivers (i.e., informal caregivers), who may or not be actual family members. In the prioritization process, the Making Healthcare Safer IV TEP noted that it may be beneficial to refine how structured communication is defined for these patient safety practices (PSPs).

1.2. Purpose of the Rapid Review

The overall purpose of this review is to summarize recent relevant literature on PSPs focused on engaging family caregivers with structured communication during care transitions and assess the effectiveness of these PSPs to improve safety during care transitions. We also sought to identify unintended harms of these PSPs as described in relevant studies.

1.3. Review Questions

1. What is the frequency and severity of harms associated with care transitions?
2. What patient safety measures or indicators have been used to examine these harms?
3. What PSPs (including Engaging Family Caregivers with Structured Communication for Safe Care Transitions) have been used to prevent or mitigate the harm and in what settings have they been used?
4. What is the rationale for these PSPs?
5. What are the effectiveness and unintended effects of these PSPs?
6. What are common barriers and facilitators to implementing these PSPs?
7. What resources (e.g., cost, staff, time) are required for implementation?
8. What toolkits are available to support implementation of these PSPs?

2.1. Eligibility Criteria for Studies of Effectiveness

We searched for original studies and systematic reviews on Review Question 5 according to the inclusion and exclusion criteria presented in Table 1. Because there is not a clear definition of what constitutes “structured communication,” we erred on the side of inclusion of interventions for improving communication with family caregivers that use standardized approaches or specific instruments/tools to structure conversations around care transitions.

Table 1

Inclusion and exclusion criteria.

2.2. Literature Searches for Studies of Effectiveness

A research librarian searched PubMed, Embase, and the Cochrane Library for relevant citations published in 2010 through June 30, 2023. We limited studies to those published in 2010 or later in order to complete this rapid review in a timely manner, and also capture all recently published studies that are likely to be relevant to current practice. A 2020 review²⁷ of a similar topic included 40 studies, and only 2 were published before 2010. We supplemented the database searches with a narrowly focused search for unpublished reports that are publicly available from governmental agencies (e.g., AHRQ) and nonprofit research organizations (e.g., Patient-Centered Outcomes Research Institute) having a strong interest in the topic. Appendix A contains the details of the search strategy.

2.3. Data Extraction (Selecting and Coding)

To efficiently identify studies that meet the eligibility criteria, the title and abstract of each citation was reviewed by a single team member. We used the DistillerSR AI Classifier Manager to identify potentially highly relevant studies excluded during the initial screening. That is, after a single team member reviewed each citation, we re-reviewed the top 30 percent of excluded abstracts noted by the AI Classifier Manager as potentially relevant. The full text of each remaining potentially eligible article were reviewed by a single team member to confirm eligibility and extract data. A second team member reviewed a randomly selected 10 percent sample of the excluded full text articles to verify that important studies were not excluded and confirm the accuracy of extracted data.

We organized information according to the review questions, and noted the author, year, study design, frequency and severity of the harms, measures of harm, characteristics of the PSP, rationale for the PSP, outcomes, implementation barriers and facilitators, required resources, and descriptions of toolkits. To streamline data extraction, we focused on extracting information about characteristics, outcomes, and barriers/facilitators most pertinent to these PSPs.

2.4. Risk of Bias (Quality) Assessment

A single reviewer assessed the risk of bias of included studies. For studies addressing Question 5 about the effectiveness of these PSPs, we used the Cochrane Collaboration’s tool for assessing the risk of bias of randomized controlled trials (RCTs) or the ROBINS-I tool for assessing the Risk Of Bias In Non-randomized Studies of Interventions.^28,29 When assessing RCTs, we used the 7 items in the Cochrane Collaboration’s tool that cover the domains of selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias.³⁰ When assessing nonrandomized studies, we used specific items in the ROBINS-I tool that assess bias due to confounding, bias in selection of participants into the study, bias in classification of interventions, bias due to deviations from intended interventions, bias due to missing data, bias in measurement of outcomes, and bias in selection of the reported results.²⁹ The risk of bias assessments focused on the main outcome of interest in each study.

2.5. Strategy for Data Synthesis

We compiled selected data into evidence tables and synthesized studies narratively. We did not conduct a meta-analysis. For Review Question 5 about the effectiveness of these PSPs, we recorded information about the context of each study and whether the effectiveness of the PSP differed across patient subgroups. We rated the strength of evidence for these PSPs using the methods outlined in the AHRQ Effective Health Care Program (EHC) Methods Guide for Effectiveness and Comparative Effectiveness Reviews,³¹ and focused on relevant outcomes listed in Table 1.

3.1. Benefits and Harms

• Structured communication with family caregivers improved family caregiver satisfaction in residential treatment discharge (Strength of evidence [SOE]: Low)
• There is insufficient evidence to assess the effect of structured communication with family caregivers on:

  • 30-day hospital readmissions
  • emergency department (ED) visits,
  • caregiver stress in hospital settings,
  • caregiver anxiety and depression
  • family/patient satisfaction for intensive care unit (ICU) transfers, and
  • symptom exacerbation in adolescents discharged from residential treatment facilities
• None of the studies reported rates of unintended harms

3.2. Future Research Needs

Future research needs include:

• methodologically rigorous studies of structured communication with family caregivers
• assessment of impacts on medication errors following care transitions
• resource requirements for implementation of structured communication with family caregivers
• assessment of potential harms or unintended consequences of interventions
• tailored interventions that include diverse patient populations and consider socioeconomic factors, spoken language, and health literacy

4.1. Number of Studies

We identified 323 unique titles and abstracts, and we assessed 86 full text articles for inclusion. Nine studies met inclusion criteria for Research Question 5 and are included in the evidence base. Figure 1 details the literature flow process. Appendix B and Appendix C provide evidence tables with additional study details and risk of bias assessments for included studies. Appendix D contains a list of studies excluded after full text review and reasons for exclusion.

Figure 1

Literature flow diagram. Abbreviations: RQ = Research Question; MA = meta-analysis; SR = systematic review

4.2. Findings for Review Questions

4.2.5. Question 5. What Are the Effectiveness and Unintended Effects of These PSPs?

Nine studies^{20,34–38,42–44} (including 1,554 patients) met our inclusion criteria. Table 2 provides an overview of the study characteristics. Two studies^37,42 were randomized controlled trials (RCTs; N=82), six studies (N=1,415) used a pre-post comparison,^{20,35,36,38,43,44} and one was a single-arm study (N=57).³⁴

Five studies^{20,34–36,38} focused on hospital discharge:

• Lion, 2023³⁴ performed a single-arm study in children of the Family Bridge Program, which had 6 primary components delivered by a trained navigator.
• Park-Clinton, 2023³⁵ performed a pre-post study of a 25-item checklist in adults.
• Peter, 2015³⁶ performed a pre-post study in adults of a 3-day educational program using teach-back methods.
• Uong, 2021³⁸ performed a pre-post study in children of the SAFER care framework, which contained prompted questions to ask medical providers.
• Huth, 2023²⁰ performed a multicomponent, pre-post study using the I-PASS framework for family and provider communication in children with medical complexity.

Three studies^37,43,44 focused on transfers from the intensive care unit (ICU):

• Gambhir, 2021⁴³ performed a pre-post study in adults of a 30-minute family meeting with a health care team
• Huynh, 2017⁴⁴ performed a pre-post study in adults of a diary that remained at bedside for the entire ICU stay
• Torke, 2016³⁷ performed a randomized trial in adults of a family navigator who conducted meetings and had structed daily contact during the ICU stay.

The final study, Becker 2021,⁴² addressed the discharge of adolescents from residential treatment centers. The treatment involved structured parenting education and access to a parent networking forum.

Regarding patient characteristics, five studies included only adult patients,^{35–37,43,44} three studies included only child patients,^20,34,38 and one study⁴² focused on adolescent patients (aged 12 to 17 years). When reported, mean patient age ranged from 1.7 years to 67 years, and the percentage of female patients ranged from 35 percent to 61 percent. Two studies^37,42 reported the mean age for caregivers which ranged from 42 to 49 years. Three studies^34,37,42 reported caregiver sex/gender which ranged between 54 percent to 87 percent female. Race and/or ethnicity of patients and/or family caregivers was reported in six studies^{34,35,37,38,42,43} (see Appendix B for additional details).

Specific patient safety practice (PSP) interventions and their duration varied widely and are described below in Tables 3 to 5 (see Appendix B for additional details). Five studies reported patient or caregiver language: one included English-speaking patients and caregivers only,³⁷ three included English-speaking and Spanish-speaking patients and caregivers,^20,38,42 and one included Spanish-speaking, English-speaking, and Somali-speaking patients and caregivers.³⁴ The timing of the delivery of interventions also varied: most interventions targeted patients and caregivers during admission and continued interventions after discharge. One study⁴³ only provided the intervention during the hospital stay (Day 6 of an ICU stay). Another study²⁰ provided a restructured discharge summary and followup calls to family caregivers after discharge. All study interventions addressed the care transition period regardless of when they were initiated during the admission and discharge process. In the two RCTs and six pre-post studies, the control group received usual care (either as a separate control group or as a pre-period before implementing the intervention); the single-arm study assessed a single group of patients at baseline and after the intervention. Followup ranged from immediately post-intervention or at discharge to 1 year.

Table 2

Characteristics of included studies.

4.2.5.1. Risk of Bias

Several types of risk of bias were present in the two included RCTs (Figure 2; Appendix C, Table C-1). We rated one RCT as moderate risk of bias,⁴² and the other as high risk of bias.³⁷ The moderate risk of bias trial had unclear randomization techniques, did not report allocation concealment, blinded outcome assessors but not patients or care providers, and did not report if they used intent to treat analysis, but attrition rates were acceptable. In the high risk of bias trial, groups were not similar at baseline, there was no blinding of patients, caregivers, or outcomes assessors, did not perform intent to treat analysis, and differential attrition between groups was high.

Figure 2

Risk of bias assessments for randomized controlled trials. Abbreviations: ITT = intention to treat; NR = not reported; ROB = risk of bias.

We rated the six pre-post studies as serious or critical risk of bias (Figure 3; Appendix C, Table C-2). Two studies^35,43 had serious risk of bias ratings with major concerns around comparable groups at baseline, ascertainment of exposures and confounders, blinding, and appropriate use of statistical analysis to account for potential confounders. We rated four pre-post studies^20,36,38,44 as critical risk of bias with concerns in all domains for all studies. We also rated the single-arm study³⁴ as critical risk of bias with concerns in all domains except for reporting attrition and loss-to-followup.

Figure 3

Risk of bias assessments for nonrandomized studies. Abbreviations: LTF = loss to followup; NA = not applicable; NR = not reported; ROB = risk of bias.

4.2.5.2. Interventions Focused on Hospital Discharge Care Transitions

Four pre-post studies^20,35,36,38 (N=more than 675; sample size not reported in one study) and one single-arm study³⁴ (n=57) compared relevant PSPs using structured communication with family or informal caregivers for patients following hospital discharge (Table 3). Below, we organized study results by pediatric and adult patient populations and summarize their methods and results.

4.2.5.2.1. Interventions focused on Hospital Discharge Care Transitions in Pediatric Populations

Two pre-post studies³⁸ (N=587) and one single-arm study³⁴ (n=57) evaluated relevant PSPs in hospitalized pediatric patients; we rated both as critical risk of bias (Table 3). Two studies targeted family/parent/informal caregivers and the other specifically targeted parent caregivers.

One critical risk of bias, pre-post study (n=433)³⁸ compared an intervention called SAFER Care (developed internally) versus usual care. The SAFER Care intervention included standardized worksheets with conversation prompts in Spanish and English and family-liaison meetings with family and informal caregivers of hospitalized general and surgical subspecialty pediatric patients. The study found no statistically significant differences in 7-day or 30-day rates of emergency department (ED) visits or hospital readmissions.

Another critical risk of bias pre-post study (n=154)²⁰ compared a multimodal intervention that adapted the I-PASS framework to improve communication with families who spoke English or Spanish and between providers of children with medical complexity following discharge from hospital to home. The study used a structured template for followup calls with family members within 24 to 48 hours of hospital discharge and EHR-based, structured templates with outpatient providers to provide hospitalization summaries and medication lists and to assign specific care responsibilities. The study assessed medical error incidents (including medication/communication errors and adverse events) following discharge, 30-day rehospitalization, and 30-day ED visits. Statistically significant differences were found in the rate per discharge of any medical error incident (0.95 [95% CI 0.73 to 1.23] vs. 1.51 [95% CI 1.27 to 1.77], p=0.003), but not in preventable adverse events, nonpreventable adverse events, nonharmful errors, or 30-day rehospitalizations. The study reported a statistically significant reduction in 30-day ED visits when analyzed using the chi-square test (3.4% [2/59] vs. 12.6% [12/95]), but our own chi-square test revealed that the difference was not statistically significant (p=0.052).

The single-arm study³⁴ used an internally developed intervention called the Family Bridge Program, consisting of 6 components delivered by a trained navigator and assessed caregiver stress using the Perceived Stress Scale-Short Form. The study reported no statistically significant differences between baseline and two to four weeks followup after hospital discharge in caregiver stress. The study included patients who spoke English, Spanish, and Somali in uninsured parent-patient dyads wherein the parent reported or the patient self-reported their ethnicity and race as non-White and non-Hispanic. Subgroup analyses for primarily English-, Somali-, and Spanish-speaking patients also showed no statistically significant differences in caregiver stress.

4.2.5.2.2. Interventions Focused on Hospital Discharge Care Transitions in Adult Populations

Two studies^35,36 (N=557) compared a preintervention period with a postintervention period and assessed relevant PSPs in hospitalized adult patients; both studies reported 30-day readmissions at different followup times (Table 3).

One serious risk of bias study³⁵ (n=88) compared using a 25-item checklist for targeted discharge planning with usual care for patients discharged from the hospital. There were no statistically significant differences in 30-day readmissions between the 16-week pre-intervention period and the ensuing 16-week post-intervention period. Of note, 35 percent of caregivers were family (i.e., informal) caregivers and 65 percent were home healthcare (i.e., trained, paid) caregivers in this study.

One critical risk of bias study³⁶ (n=469) used a pre-post study design to evaluate the impact of a teach-back intervention on 30-day hospital readmissions in adults with heart failure. The care team identified “key-learners” as the primary recipient of the intervention, which could include patients or informal caregivers. The study did not report statistical tests, but noted a 12 percent reduction in 30-day hospital readmissions at 1-year followup among patients receiving the teach-back intervention.

Table 3

Details of studies focused on hospital discharge care transitions.

4.2.5.3. Interventions Focused on ICU Care Transitions

One small, high risk of bias RCT³⁷ (n=21) and two pre-post studies^43,44 with serious and critical risks of bias (N=271) assessed relevant PSPs for ICU care transitions in adult patients (Table 4). The RCT compared a multicomponent family navigator intervention using structured communication and family meetings with surrogate decision makers in patients with severe cognitive impairment with usual care alone. The RCT assessed caregiver anxiety using General Anxiety Disorder-7 instrument and depression using the Patient Health Questionnaire-9 instrument and found no statistically significant differences at 6- to 8-week followup between groups for either outcome.

The two studies^43,44 evaluating interventions for ICU transfers compared a pre-intervention period with a post-intervention period. One study⁴³ with serious risk of bias (n=71) compared using 30-minute family meetings with family caregivers versus usual care. The study assessed patient satisfaction with discharge instructions using a 5-point Likert scale on Day 6 of the ICU stay. Patients receiving family meetings were more likely to report being mostly or completely satisfied with discharge instructions (89.7% vs. 57.1%, RR 1.57 (95% CI 1.17 to 2.10). The other critical risk of bias study⁴⁴ (n=200) implemented an ICU diary intervention in adult patients and their family caregivers in the medical/surgical ICU and the cardiovascular ICU at a single institution. ICU nurses encouraged patients and caregivers to bring their diaries to followup appointments after discharge. There were no statistically significant differences in family satisfaction or family decision making at patient discharge. One aim of the study was to increase referrals to a post-ICU clinic and found slightly higher referrals in the intervention group (8.8 referrals per month vs. 5 referrals per month; statistical tests for significance not reported).

Table 4

Details of studies focused on transfers from intensive care units.

4.2.5.4. Interventions Focused on Other Care Transitions

One moderate risk of bias RCT⁴² (Table 5; N=61) assessed the impact of a program (Parent SMART [Substance Misuse in Adolescents in Residential Treatment]) for adolescent patients with substance misuse being discharged from short- and long-term residential treatment centers. The study analyzed effects of the intervention on symptom exacerbation (i.e., proportion of days using alcohol, cannabis, and any substance and substance-related problems) and caregiver satisfaction using the Customer Satisfaction Questionnaire. Outcomes were assessed at week 6, week 12, and week 24 following discharge. There were no statistically significant differences between the Parent SMART group and the usual care group in the proportion of days of alcohol use, cannabis use, or any substance use. Parent caregivers reported higher satisfaction with treatment in the Parent SMART group (88% vs. 59%, p=0.02).

Table 5

Details of studies focused on other care transitions.

4.2.5.5. Harms Associated With Relevant PSPs

No studies reported harms or unintentional outcomes specifically related to the interventions. One RCT⁴² reported a single study withdrawal in the intervention group, but did not provide a reason.

4.2.6. Strength of Evidence

Our strength of evidence ratings appear in Table 6 below. Most studies of PSPs across represented care transitions provided insufficient evidence to draw conclusions about their effectiveness with one exception. We found Low strength of evidence that PSPs in residential treatment care transitions improved caregiver satisfaction based on one RCT (N=61).⁴²

Table 6

Strength of evidence ratings.

4.2.7. Question 6. What Are Common Barriers and Facilitators to Implementing These PSPs?

Six studies^{35–38,42,44} reported facilitators for implementing PSPs, and two studies^35,44 noted barriers to implementation. Table 7 provides implementation facilitators and barriers described in the included studies.

Table 7

Patient safety practice implementation facilitators and barriers.

5.1. Summary and Interpretation of Findings

During and after transitions of care, patients are particularly vulnerable to adverse events, and lack of clear communication with caregivers can increase the risk of harms occurring. Included studies evaluated the effect of PSPs on a variety of outcomes including emergency department (ED) use, hospital readmission, caregiver stress, caregiver anxiety, caregiver depression, symptom exacerbation, and patient/caregiver satisfaction. Many of the interventions we included for Review Questions 5 on benefits and harms of these PSPs used components that allowed clinical providers to listen to caregivers’ concerns, assess caregivers’ understanding of medical care and discharge instructions, and correct any misunderstandings. Thus, they went far beyond mere one-way patient education. Patient levels of understanding, while necessary for good communication and an important outcome in this field, was outside the scope of this rapid review as it is a surrogate/intermediate outcome, and we focused on direct clinical and patient-related outcomes.

We included nine studies^{19,34–38,42–44} conducted in the United States assessing the impact of structured communication with family caregivers during care transitions for hospital, intensive care unit (ICU), and residential treatment care transitions. Studies employed different patient safety practice (PSP) interventions, but all involved a component to structured communication with family caregivers and, in some studies, patients. Unfortunately, they provided insufficient strength of evidence to permit conclusions for most outcomes (see Table 6 for details). Relevant PSPs improved parent caregiver satisfaction in residential treatment discharge transitions (one study, N=61; SOE: Low).

Included studies did not quantify or detail resource requirements to implement PSPs. The PSPs varied greatly in complexity: some implemented PSPs using a single checklist to guide conversations, while others implemented multicomponent interventions using patient navigators which requires specially trained staff to provide patients and caregivers with support. When healthcare organizations consider implementing these types of interventions, key considerations include sufficient access to materials, staff capacity, and technology requirements.

5.2. Limitations

Most studies we included were not designed as research studies and, therefore, have questionable internal validity. Included studies reported on a number of outcomes related to different care transitions, but none reported on medication errors, and there were only three types of transitions of care represented in our included studies (ICU transfers, hospital to home, and residential treatment discharge). Similarly, only one study⁴² reported any harms or unintended consequences related to the PSP, but did not provide a reason. Additionally, four studies used multicomponent interventions,^19,34,37,42 thus making it difficult to determine the effectiveness of individual intervention components. Finally, little evidence exists on the resources required to implement these PSPs (e.g., staff expertise, time requirements).

Because of the rapid nature of this review, we did not use full dual review of abstracts, full-text, or risk of bias assessments, and therefore we may have excluded relevant studies. However, to mitigate this, we were intentionally overly inclusive during our abstract review and used Distiller’s artificial intelligence to identify any “near misses” at the full-text level. A second reviewer also reviewed 30 percent of abstract excludes and the top 10 percent of full text excludes to ensure we comprehensively included relevant studies. Given the rapid nature of this review, we also only included studies conducted in the United States and published in 2010 or later. We excluded nine studies^61–69 that otherwise met inclusion criteria because they were conducted outside of the United States (3 in Iran, 2 in Turkey, and 1 each in China, India, the UK, and Uganda). It is possible some relevant studies were conducted before 2010 (number unknown because the searches only went to 2010). We also did not include outcomes assessing patient or caregiver understanding of care transition instructions.

Finally, it is unclear what constitutes “structured communication,” and no standardized definition exists. We therefore were broadly inclusive of interventions using communication techniques that provided some form of structure with family caregivers (e.g., teach-back, checklists, caregiver education programs, patient-navigator PSPs). We erred on the side of inclusion if studies used a tool to communicate or described a process for communication, but we excluded education-only interventions (e.g., one-way transfers of information) or communication without a tool or formal process. Identifying a standardized definition of “structured communication” would be helpful in order for future research to better compare the effect of related interventions.

5.3. Implications for Clinical Practice and Future Research

Evidence indicates that structured communication practices can improve caregiver satisfaction, but there is insufficient evidence to draw conclusions on other important outcomes. Healthcare organizations looking to implement these PSPs need to consider resource requirements which are difficult to specify and depend on the setting, organization, and existing infrastructure. Using technology-based components may improve access to resources for patients and caregivers and may facilitate implementation of PSPs, but also introduces other challenges to implementation. Team capacity to develop or select specific PSPs and to deliver interventions effectively is another high-priority consideration. Relevant PSPs may also improve outcomes we did not include here. Therefore, it is important for healthcare organizations to consider their capacity, existing infrastructure, resources required, and targeted goals prior to implementing new structured communication PSPs.

There are a number of future research needs related to these PSPs. First, there is a need for well-designed, adequately powered, randomized controlled trials or prospective nonrandomized controlled studies to assess the effect of these PSPs in different care transitions. Future research also needs to report on additional outcomes, especially medication errors, which were absent in our included studies except for one¹⁹ that combined this outcome with communication errors between providers. Also, future studies should explicitly analyze outcomes related to healthcare disparities and report subgroup analyses for populations who disproportionately experience healthcare disparities. In the context of communication, language proficiency, availability of quality translators—if needed—and healthcare-related literacy and numeracy are important considerations for future research. Further, there is a lack of evidence in published studies related to the resources needed to implement these PSPs, and unintentional harms. Ultimately, implementing structured communication interventions for family caregivers during care transitions is a worthwhile effort and may reduce adverse events, enhance clinical effectiveness, impact care utilization, patient/caregiver satisfaction, and clinician/provider satisfaction.

Appendix A. Literature Search Strategies

Appendix B. Evidence Tables

See accompanying Excel file at https://effectivehealthcare.ahrq.gov/products/engaging-caregivers-mhs4/rapid-research for detailed evidence tables of included studies.

Table B-1. Details of included studies (MS Excel, 30K)

Appendix C. Risk of Bias Assessment

See accompanying Excel file at https://effectivehealthcare.ahrq.gov/products/engaging-caregivers-mhs4/rapid-research for risk of bias assessments for included studies.

Table C-1. Risk of bias for randomized controlled trials (MS Excel, 16K)

Table C-2. Risk of bias for nonrandomized studies (MS Excel, 16K)

Appendix D. List of Excluded Studies With Reasons Upon Full-Text Review

1.

Alisic E, Barrett A, Bowles P, et al. Ear for recovery: Protocol for a prospective study on parent-child communication and psychological recovery after paediatric injury. BMJ Open. 2015 Feb;5(2):e007393. doi: 10.1136/bmjopen-2014-007393. PMID: 25652805. Exclusion reason: Ineligible publication type [PMC free article: PMC4322211] [PubMed: 25652805] [CrossRef]

2.

Amirani L, Namnabati M, Hajiheidari M. Examining the effect of discharge plan on enabling mothers of preterm babies admitted to the neonatal intensive care unit (NICU). Ann Trop Med Public Health. 2018;13(Special Issue):SX746. https://www​.atmph.org/. Exclusion reason: Unable to retrieve publication

3.

Anderson C, Deepak BV, Amoateng-Adjepong Y, Zarich S. Benefits of comprehensive inpatient education and discharge planning combined with outpatient support in elderly patients with congestive heart failure. Congest Heart Fail. 2005;11(6):315–21. doi: 10.1111/j.1527-5299.2005.04458.x. PMID: 16330907. Exclusion reason: Ineligible population [PubMed: 16330907] [CrossRef]

4.

Ariza-Vega P, Ortiz-Piña M, Mora-Traverso M, et al. Development and evaluation of a post-hip fracture instructional workshop for caregivers. J Geriatr Phys Ther. 2020 Jul;43(3):128–36. doi: 10.1519/JPT.0000000000000230. PMID: 30913137. Exclusion reason: Ineligible study design [PubMed: 30913137] [CrossRef]

5.

Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;23(8):1228–33. doi: 10.1007/s11606-008-0618-9. PMID: 18452048. Exclusion reason: Ineligible population [PMC free article: PMC2517968] [PubMed: 18452048] [CrossRef]

6.

Bangirana P, Birabwa A, Nyakato M, et al. Use of the creating opportunities for parent empowerment programme to decrease mental health problems in Ugandan children surviving severe malaria: A randomized controlled trial. Malar J. 2021 Jun;20(1):267. doi: 10.1186/s12936-021-03795-y. PMID: 34120616. Exclusion reason: Ineligible country [PMC free article: PMC8201864] [PubMed: 34120616] [CrossRef]

7.

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48.

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