Multicomponent transitional care interventions for older adults were associated with modest short-term reductions in hospital readmissions and emergency department visits, alongside improvements in functional status and mood.
Systematic Review (n=17,542)
Do transitional care interventions improve clinical and patient-reported outcomes in older adults aged 65 and older transitioning from hospital to home?
Multicomponent transitional care interventions can improve short-term functional status and reduce hospital readmissions for older adults, though long-term benefits remain uncertain.
The global ageing population presents growing challenges for health and social care systems, particularly during transitions from hospital to home for older adults. These high-risk periods are associated with functional decline, hospital readmissions, and reduced quality of life. This systematic review synthesised evidence from 25 randomised controlled trials (RCTs), involving 17,542 participants aged 65 and older, to evaluate the effectiveness of transitional care interventions. A comprehensive search of PubMed, CINAHL Complete, and Scopus was conducted for studies published between January 2013 and March 2024. Outcomes were categorised using the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy into four domains: clinical outcomes, life impact, resource use, and death/adverse events. Most interventions were multicomponent, combining structured discharge planning, caregiver involvement, follow-up, and home-based support, typically delivered by multidisciplinary teams. Interventions were frequently associated with improvements in functional status, mood, and nutritional outcomes, as well as modest reductions in hospital readmissions and emergency department visits in the short term. Few studies assessed outcomes beyond six months, and sustained effects were uncommon. Few interventions demonstrated effects on mortality or adverse events. Caregiver engagement, particularly involving informal caregivers, and early post-discharge follow-up emerged as key enablers of success. Due to considerable heterogeneity in intervention design and outcomes, findings were synthesised narratively. This review highlights the potential of personalised, interdisciplinary transitional care models tailored to the complex needs of older adults. Future research should prioritise long-term outcomes, patient-reported experiences, and the development of scalable, context-sensitive strategies, including digital tools and caregiver-inclusive approaches.
Steiner et al. (Wed,) conducted a systematic review in Hospital-to-home transitions (n=17,542). Transitional care interventions vs. Usual or standard care was evaluated on Clinical outcomes, life impact, resource use, and death/adverse events. Multicomponent transitional care interventions for older adults were associated with modest short-term reductions in hospital readmissions and emergency department visits, alongside improvements in functional status and mood.