A total of 24 studies were included in this systematic review. Of these studies, 13 were qualitative, 7 were quantitative and 4 used mixed method designs. Studies were conducted in The United States (n=9, 38%), Australia (n=5, 21%), Sweden (n=3, 13%), The Netherlands (n=2, 8%), The United Kingdom (n=2, 8%), Canada (n=1, 4%), New Zealand (n=1, 4%) and Norway (n=1, 4%). Health professionals in these studies included nurses, nurse practitioners, doctors, medical students, occupational therapists, dieticians, physiotherapists, speech and language pathologists, social workers and case managers. Table 1 outlines the included study characteristics; Figure 1 presents the study PRISMA flow diagram [35].
Overall study quality was rated as acceptable across all appraisal checklists, with all relevant studies met at least minimal standards of adequacy in accordance with their respective quality appraisal tools. The summary of the results of quality appraisals for qualitative, quantitative and mixed method studies are presented in Tables 2a, 2b and 2c respectively. Findings were summarized to address the two research questions separately and narratively synthesized to develop the themes. The characteristics of the different communication methods for each study are categorized according to Berlo’s Model of Communication [28] in Table 3, highlighting the roles and processes of different healthcare professions, healthcare teams and healthcare settings. Clear categorization was not possible where study samples included both hospital-based and community-based healthcare professionals but generally, hospitals were the senders or source of discharge communication to primary care practitioners, the intended receivers of patient information, using various messages and/or channels.
Effective methods and/or models of communication between inpatient allied health professionals and primary care practitioners
None of the included studies specifically investigated the methods of communication or evaluated the effectiveness of communication between hospital allied health professionals and primary care practitioners. Twelve of the 24 studies, however, described programs or processes that indirectly addressed components of communication between hospital allied health professionals and primary care practitioners [5, 8, 36-45]. Narrative synthesis of each study included exploration of these 12 interventions within the context of their relationship to some guiding theoretical models of care, namely the chronic care model [46], the collaborative care model [47] and the integrated care model [48]. The relevance of the theoretical underpinnings of each model of care will be briefly discussed in relation to evolving healthcare practice, based on our analyses of these 12 interventions from the included studies.
Chronic Care Model
A descriptive paper by Allen et al. in 2004 described the theoretical basis for a randomized trial of a comprehensive post discharge care management program, STEPS CARE [36]. The report included details of a clinical information system that allowed hospital care plans to be communicated directly to primary care. Within the descriptive paper, the authors ascribed what they termed a chronic care model to their program [36] however, has since become recognized as a proactive, person-centered, evidence-based approach with features more consistent with a collaborative care model [47].
Collaborative Care Model
Chronic care management has evolved to incorporate a collaborative care model, which includes the active engagement of hospital and primary care providers in the shared care of patients beyond usual discharge summaries [47]. All 12 of the interventions identified in the literature [5, 8, 36-45] included features consistent with a collaborative model of care in their initiatives to improve hospital discharge planning and continuity of care, even though they did not all reference a theoretical basis.
A collaborative care model may have formed the theoretical framework for the ‘Accountable Care in Transitions Program’ [5] described by Hawes et al. (2017), however was not specifically named. A well-coordinated, multidisciplinary team approach was used within the outpatient transition setting to support patients in the community after hospital discharge, facilitated by direct communication between social workers acting as care managers in both the hospital and in the primary care setting [5]. Social workers too, were described as ‘boundary spanners’ to facilitate communication between a medical cancer centre and primary care in an intervention described by Flieger et al. in 2019 [37]. In this study, the payment and delivery system innovation adapted an identified chronic care management model to become a more collaborative model of care. The reform prompted the routine sharing of information between the hospital social workers and the primary care chronic care coordinators, allowing improved care coordination and communication across healthcare settings [37].
Improved communication between the hospital and primary care providers was also attributed to hospital allied health professionals, in a retrospective report by Holmes et al. in 2017, describing the trial of a new allied health service in an emergency department [39]. The pilot project indicated that the inclusion of a combined social work and physiotherapy service increased patient links to primary care after hospital discharge. Stakeholder and staff feedback via a questionnaire suggested communication had improved between the hospital and primary care [39], however objective data was not provided so the findings need to be interpreted with caution.
Early attempts to use information technology (IT) to improve the hospital-primary care interface were described by two earlier studies. An electronic data linking system evaluated by Massy-Westropp et al. in 2005 [41] allowed hospital access to a primary care data base and alerted primary care providers to patient discharge from hospital. A study by Wilson et al. in 2004 [45] indicated that using videoconferencing between the hospital multidisciplinary team and primary care providers provided a better patient management plan than telephone conferencing [45]. Unfortunately, both studies relied on the opinions of a small sample of staff rather than finding statistically significant measures of effect, so the findings are difficult to generalize.
Health IT developments have enabled more sophisticated programs to measure and improve care coordination such as those described by Thomas and Siaki (2017) [43] and Hsiao et al. (2018) [40]. Both interventions are comprehensive, multidisciplinary approaches to facilitate communication of hospital discharge plans with primary care through the integration of electronic health records, promotion of patient engagement and ongoing monitoring of patients to ensure timely follow up with primary care. Both studies concluded that more efficient IT systems are required to support improved communication across the healthcare continuum [40, 43]. Hsiao et al. suggested that access to hospital medical records (inclusive of allied health documentation) enhanced primary care outcomes and recognized the need for input from community-based organisations to address social and economic issues [40]. This integrated model of care, which they identified as a ‘care coordination approach’, was reported to strengthen relationships between the hospital and community healthcare [40].
Integrated Care Model
Hesselink et al. [38] used an intervention mapping framework, commencing first with a systematic review of effective discharge interventions, to develop a comprehensive guide to improve communication between hospital and primary care. Integrated care was identified as one of the theory-based methods used to identify that discharge templates, a liaison person, reconciliation of medication and regular site visits were strategies to support high-quality discharge information, well-coordinated care, and direct and timely communication with primary care [38]. As mental healthcare and social services were not mentioned in the study, it would seem that these strategies were more closely aligned with a collaborative model of care than an integrated model of care.
As one component of an identified ‘integrated program of services’, McAiney et al. [42] described the role of an intensive geriatric service worker, developed to address the challenges faced by seniors transitioning from hospital to community care that place them at risk of poor outcomes including preventable hospital readmission. A theoretical model was not specifically mentioned however, the intensive geriatric service worker role was developed with the collaboration of a geriatric health services network and a community-based mental health service to help seniors navigate a complex and disjoined healthcare system [42].
In another example of the extension of a collaborative model of care, Trankle et al. [44] noted that integrated care aims to improve communication, not just between hospitals and primary care but also between physical care and mental healthcare, as well as between healthcare and social care. The authors evaluated a program, the Western Sydney Integrated Care Program, which enabled shared patient care plans to be developed and accessed by hospital and community healthcare providers and patients. Within this broader evaluation, it was concluded that the program improved patient and carer experience of healthcare and built capacity in primary care, acknowledging electronic communication across healthcare sectors remained difficult [44].
The ‘Advanced Care Coordination Program’ proposed by Miller et al. [8] seemed similarly to be based on an integrated model of care, to address the gaps in care during patient care transitions, although a theoretical framework was not discussed. Their social worker-led program focused on social determinants of health in a comprehensive and longitudinal care coordination intervention. The core components of care coordination were initial notification of patient hospital admission, a comprehensive needs assessment, clinical intervention as indicated and a phone call to the primary care providers [8]. The comprehensive needs assessment addressed access to health care, economic status, housing status, psychological status, and social support. The program included the development of a shared data base, as well as the provision of continuing education and outreach to bridge healthcare and social care communication after hospital discharge [8].
To summarise, while no specific methods or measures of communication between hospital allied health professionals and primary care practitioners were evaluated, elements of a collaborative care model [47] seemed to underpin the majority of studies describing interventions to improve discharge planning and communication between hospital settings and primary care settings. The more recent studies suggest that the collaborative model of care can evolve to become an integrated model of care, providing a theoretical framework for interventions to facilitate collaboration between healthcare and community services, including mental healthcare and social care services. There were some common concepts and components identified in the included studies which have helped and hindered general communication within and between hospital and primary care, which will be further discussed in relation to the enablers and barriers highlighted within each study.
Enablers and barriers to effectivecommunication between hospital allied health professionals and primary care practitioners.
Coding of the literature allowed identification of the four most common themes in relation to components and processes of communication between hospital and primary care, allowing an insight into the factors affecting communication between hospital allied health professionals and primary care practitioners. The four emerging themes of ‘multidisciplinary care plans’, ‘patient and caregiver involvement’, ‘health information technology’ and ‘follow up’, are outlined in Table 4 as the enablers to communication, however they have their own barriers as described below and included in Table 5.
Multidisciplinary care plans
Multidisciplinary care plans were important components of the 12 interventions aiming to improve communication processes between hospitals and primary care [5, 8, 36-45]. The remaining 12 studies [49-60] assumed or suggested that multidisciplinary care plans were a means of facilitating healthcare communication, as outlined in Table 4. There were, however, multiple barriers to the practice and process of multidisciplinary care plans/planning mentioned in the 24 included studies, including ineffective relationships between health professions [49-55], junior doctors responsible for the discharge summary [53] and allied health reports and recommendations omitted from the care plan [49, 56].
Patient and caregiver involvement
According to the World Health Organisation, person-centered care takes into account the patient’s values, beliefs and preferences while encouraging them to actively participate in their own individualized care plan [7]. Involving the patient and their caregiver in care planning and encouraging self-management was incorporated in 18 (75%) of the 24 included studies [5, 8, 36-40, 42-44, 50-55, 58, 59] as seen in Table 4. Several of the studies reported negative patient experiences of the discharge process where they did not feel sufficiently involved or informed [38, 42, 51, 53].
Despite theoretical models, healthcare policies and hospital guidelines, it seems barriers remain to the involvement of patients in their own care planning, preventing healthcare practice from being truly person-centered and compromising initiatives to become more people-centered. Two studies focused specifically on unmet communication needs of patients and their caregivers leading to issues with continuity of care [51, 52]. Other studies found some patients do not dare to speak up [38] and/or are unable to comprehend information or be too medically unstable to contribute to discharge planning [53]. Furthermore, healthcare professionals may not feel equipped to broach certain topics with patients and caregivers [59]. Insufficient time and knowledge to allow effective communication with patients and caregivers [49, 53] could be further barriers to involving patients and their caregivers in the planning of care.
Health information technology
There was a general consensus in the literature with 17 (71%) of the 24 included studies suggesting that advances in health IT may offer a promising solution to the inconsistency of healthcare communication [5, 8, 36-38, 40, 41, 43, 44, 51-58], as seen in Table 4, but multiple barriers to its implementation were identified. Logistical barriers to health IT include the lack of staff access and training [41, 60], lack of appropriate technology [36, 40] and system incompatibility [8, 37, 38, 44].
Follow-up
In the absence of consistent, compatible health IT systems to share care plans and standardize communication across healthcare settings, the importance of a designated person to support the transition of care was highlighted by 19 (79%) of the 24 included studies [5, 8, 36-40, 42-44, 49, 50, 52-54, 56-59] as seen in Table 4. ‘Care manager’ and ‘case manager’ were the most common titles attributed to the healthcare professional identified to follow up patients after hospital discharge [5, 36, 43, 49, 54], however they were also referred to as ‘chronic care coordinator [37], ‘transition guide’ [40], ‘care facilitator’ [44] ‘health coach’[53], and ‘intensive geriatric service worker’ [42]. One study recommended that an occupational therapist and a geriatrician should provide post discharge follow up and communicate with primary care practitioner [50]. Other studies recommended various healthcare professionals could provide follow up and communication with primary care: a liaison nurse or pharmacist [38], nurse practitioner [60] advanced practice nurse [52] or social worker [39].
Four studies of the five studies that did not refer to a designated person to provide follow up suggested alternative processes to encourage patient follow up by primary care; two of them recommended primary care providers be involved in hospital discharge planning meetings [55, 60], another relied on an automated hospital discharge alert system [41] and one recommended patient provision of follow up service information, including whom to call if follow up does not occur [51]. Unlike the interventions recommending a designated person to provide follow up, these four studies [41, 51, 55, 60] did not include a process to ensure follow up had occurred after hospital discharge.
The main barrier to a designated person to follow up and ensure continuity of care appear to be ineffective relationships between healthcare organisations, due to and resulting in a lack of collaboration between healthcare providers [49] and between healthcare settings [38, 52-54, 56-58]. Siloed healthcare is clearly a contributing factor [38, 50, 53, 54], resulting in one-way communication [50], with hospital discharge summaries often not arriving in time to be relevant to primary care practitioners [52, 58] and without establishing a shared understanding by determining if information is according to need and/or understood [53].
Multidisciplinary care plans that are collaborative and person-centered may be a common goal, however, there is little evidence in the literature to determine their quality, consistency or whether they support or are supported by effective communication between hospital allied health professionals and primary care practitioners. A word frequency search across all of the included studies using NVivo software [31] revealed that the term ‘communication’ was not one of the ten most frequent words, only appearing in the 50 most frequent words [see Figure 2], despite the accepted understanding that communication is one of the corner stones of collaborative healthcare [61].
In summary, enablers to effective communication between hospital allied health professionals and primary care practitioners are multidisciplinary care plans, made in collaboration with patient and relevant caregivers, and electronically communicated to primary care, with a designated person to follow up to ensure that there is continuity of care in the community. The barriers to such communication include that hospital discharge communication can remain disease focused and may not include allied health recommendations or the preferences of patients and their caregivers. Even when multidisciplinary care plans aimed to be collaborative and person-centered or ideally based on a people-centered integrated model of care [7], health IT systems were reported to be insufficiently compatible such that consistent, auditable, reciprocal communication between hospitals and primary care was not possible.