abstract: 'Background: Older adults experience a high risk of adverse events during

  hospital-to-home transitions. Implementation barriers have prevented

  widespread clinical uptake of the various digital health technologies

  that aim to support hospital-to-home transitions.

  Objective: To guide the development of a digital health intervention to

  support transitions from hospital to home (the Digital Bridge

  intervention), the specific objectives of this review were to describe

  the various roles and functions of health care providers supporting

  hospital-to-home transitions for older adults, allowing future

  technologies to be more targeted to support their work; describe the

  types of digital health interventions used to facilitate the transition

  from hospital to home for older adults and elucidate how these

  interventions support the roles and functions of providers; describe the

  lessons learned from the design and implementation of these

  interventions; and identify opportunities to improve the fit between

  technology and provider functions within the Digital Bridge intervention

  and other transition-focused digital health interventions.

  Methods: This 2-phase rapid review involved a selective review of

  providers'' roles and their functions during hospital-to-home transitions

  (phase 1) and a structured literature review on digital health

  interventions used to support older adults'' hospital-to-home transitions

  (phase 2). During the analysis, the technology functions identified in

  phase 2 were linked to the provider roles and functions identified in

  phase 1.

  Results: In phase 1, various provider roles were identified that

  facilitated hospital-to-home transitions, including navigation-specific

  roles and the roles of nurses and physicians. The key transition

  functions performed by providers were related to the 3 categories of

  continuity of care (ie, informational, management, and relational

  continuity). Phase 2, included articles (n=142) that reported digital

  health interventions targeting various medical conditions or groups.

  Most digital health interventions supported management continuity (eg,

  follow-up, assessment, and monitoring of patients'' status after hospital

  discharge), whereas informational and relational continuity were the

  least supported. The lessons learned from the interventions were

  categorized into technology- and research-related challenges and

  opportunities and informed several recommendations to guide the design

  of transition-focused digital health interventions.

  Conclusions: This review highlights the need for Digital Bridge and

  other digital health interventions to align the design and delivery of

  digital health interventions with provider functions, design and test

  interventions with older adults, and examine multilevel outcomes.'
affiliation: 'Singh, H (Corresponding Author), Univ Toronto, Temerty Fac Med, Dept
  Occupat Sci \& Occupat Therapy, 500 Univ Ave, Toronto, ON M5G 1V7, Canada.

  Singh, Hardeep, Univ Toronto, Temerty Fac Med, Dept Occupat Sci \& Occupat Therapy,
  500 Univ Ave, Toronto, ON M5G 1V7, Canada.

  Singh, Hardeep; Armas, Alana; Nelson, Michelle L. A., March Dimes Canada, Toronto,
  ON, Canada.

  Singh, Hardeep; Heffernan, Matthew, Univ Toronto, Temerty Fac Med, Rehabil Sci Inst,
  Toronto, ON, Canada.

  Singh, Hardeep, Univ Hlth Network, Toronto Rehabil Inst, Toronto, ON, Canada.

  Tang, Terence; Plett, Donna; Law, Susan; Nie, Jason Xin, Trillium Hlth Partners,
  Inst Better Hlth, Mississauga, ON, Canada.

  Tang, Terence, Univ Toronto, Dept Med, Toronto, ON, Canada.

  Gray, Carolyn Steele; Thombs, Rachel; Armas, Alana; Nelson, Michelle L. A., Sinai
  Hlth Syst, Collaboratory Res \& Innovat, Lunenfeld Tanenbaum Res Inst, Toronto,
  ON, Canada.

  Gray, Carolyn Steele; Plett, Donna; Law, Susan; Ellen, Moriah E.; Nelson, Michelle
  L. A., Univ Toronto, Dalla Lana Sch Publ Hlth, Inst Hlth Policy Management \& Evaluat,
  Toronto, ON, Canada.

  Kokorelias, Kristina, Sunnybrook Hlth Sci Ctr, Sunnybrook Res Inst, St Johns Rehab
  Res Program, Toronto, ON, Canada.

  Jarach, Carlotta M., Ist Ric Farmacol Mario Negri IRCCS, Dept Environm Hlth Sci,
  Milan, Italy.

  Cunningham, Heather, V, Univ Toronto, Gerstein Sci Informat Ctr, Toronto, ON, Canada.

  Ellen, Moriah E., Ben Gurion Univ Negev, Dept Hlth Policy \& Management, Guilford
  Glazer Fac Business \& Management, Beer Sheva, Israel.

  Ellen, Moriah E., Ben Gurion Univ Negev, Fac Hlth Sci, Beer Sheva, Israel.

  Thavorn, Kednapa, Ottawa Hosp, Clin Epidemiol Program, Res Inst, Ottawa, ON, Canada.

  Thavorn, Kednapa, Univ Ottawa, Sch Epidemiol \& Publ Hlth, Ottawa, ON, Canada.'
article-number: e35929
author: Singh, Hardeep and Tang, Terence and Gray, Carolyn Steele and Kokorelias,
  Kristina and Thombs, Rachel and Plett, Donna and Heffernan, Matthew and Jarach,
  Carlotta M. and Armas, Alana and Law, Susan and Cunningham V, Heather and Nie, Jason
  Xin and Ellen, Moriah E. and Thavorn, Kednapa and Nelson, Michelle L. A.
author-email: hardeepk.singh@mail.utoronto.ca
author_list:
- family: Singh
  given: Hardeep
- family: Tang
  given: Terence
- family: Gray
  given: Carolyn Steele
- family: Kokorelias
  given: Kristina
- family: Thombs
  given: Rachel
- family: Plett
  given: Donna
- family: Heffernan
  given: Matthew
- family: Jarach
  given: Carlotta M.
- family: Armas
  given: Alana
- family: Law
  given: Susan
- family: Cunningham V
  given: Heather
- family: Nie
  given: Jason Xin
- family: Ellen
  given: Moriah E.
- family: Thavorn
  given: Kednapa
- family: Nelson
  given: Michelle L. A.
da: '2023-09-28'
doi: 10.2196/35929
eissn: 2561-7605
files: []
journal: JMIR AGING
keywords: transitions; health; medical informatics; aged; mobile phone
keywords-plus: 'RANDOMIZED CONTROLLED-TRIAL; IMPROVING CARE TRANSITIONS; OBSTRUCTIVE

  PULMONARY-DISEASE; PATIENTS AFTER-DISCHARGE; QUALITY-OF-LIFE;

  OLDER-ADULTS; FOLLOW-UP; HEART-FAILURE; SELF-MANAGEMENT; ELECTRONIC

  DISCHARGE'
language: English
month: APR-JUN
number: '2'
number-of-cited-references: '259'
orcid-numbers: 'Jarach, Carlotta Micaela/0000-0002-9963-1624

  Jarach, Carlotta Micaela/0000-0002-9963-1624

  Heffernan, Matthew/0000-0001-7270-2069

  Kokorelias, Kristina/0000-0002-1277-472X

  Armas, Alana/0000-0002-7664-3294

  Singh, Hardeep/0000-0002-7429-5580

  Plett, Donna/0000-0001-8457-7218

  Thombs, Rachel/0000-0002-3915-2234

  Tang, Terence/0000-0002-1735-7298

  Steele Gray, Carolyn/0000-0002-2146-0001'
papis_id: e6d39721b1bf7ea031717b9fb9c3f03d
ref: Singh2022recommendationsdesig
researcherid-numbers: 'Tang, Terence/HNQ-7020-2023

  Jarach, Carlotta Micaela/AAA-5148-2022

  Jarach, Carlotta Micaela/GQH-8460-2022

  '
tags:
- relevant
- review
times-cited: '1'
title: 'Recommendations for the Design and Delivery of Transitions-Focused Digital
  Health Interventions: Rapid Review'
type: Review
unique-id: WOS:000798395200024
usage-count-last-180-days: '2'
usage-count-since-2013: '5'
volume: '5'
web-of-science-categories: Geriatrics \& Gerontology; Gerontology; Medical Informatics
year: '2022'