Table 2

Predischarge, postdischarge and bridging transitions scope of practice (SOP) of APNs within APN-led models of care within clinical settings

rStudy	Allen et al59	Hirschman and Bixby60	Litaker et al62	Li et al61	Zimmerman et al63
Predischarge SOP
Screening, assessment, comprehensive needs assessment		✓		✓
Patient-centred care, Individualised care and care planning		✓		✓	✓
Education, counselling and coaching		✓		✓	✓
Collaboration		✓			✓
Medication management, adjustment, education, reconciliation		✓		✓	✓
Management, monitoring, action planning and red flag identification				✓	✓
Coordination		✓
Documentation		✓		✓	✓
Postdischarge SOP
Assessment			✓	✓
Individualised care, care planning and treatment regimes	✓	✓	✓		✓
Collaboration	✓	✓	✓		✓
Medication management, reconciliation, adjustment, monitoring, prescribing	✓	✓	✓		✓
Management, monitoring, action planning and red flag identification	✓	✓	✓		✓
Follow-up care:
Home visits	✓	✓			✓
Telephone calls	✓	✓	✓	✓	✓
Office visits	✓		✓
By mail				✓
Education, counselling and coaching	✓	✓	✓		✓
Documentation	✓	✓	✓	✓	✓
Bridging transition SOP
Transition coach		✓			✓
Patient-centred transitions instructions		✓			✓