Feasibility and acceptability of nurse-coordinated transitional care for acutely ill complex older adults: trial within a cohort study (TRANSFER-II) protocol

Background: Transitioning from hospital to home signifies a risk for older adults, often resulting in worse health outcomes and increased healthcare utilisation. Frailty, recognised as a critical issue and global health priority in geriatric care, further compounds these transition risks. There is a need to generate new knowledge of effective interventions for these populations that address this vulnerable period during the transfer home.Aim: To evaluate the feasibility and acceptability of a nurse-coordinated discharge intervention for acutely ill complex older adults discharging home.Design: Prospective, non-randomised, single-arm, feasibility and acceptability Phase I trial within a cohort study protocol.Methods: Eligible participants are individuals aged 65 years and over, admitted under the Geriatric Services of two metropolitan hospitals, included in the Western Sydney Clinical Frailty Registry and discharged from hospital to home. All participants are provided with the intervention, which includes phone-based patient-centred discharge communication initiated during the transfer from hospital to home. The primary outcome is the feasibility and acceptability of the intervention, assessed by the proportion of participants able to agree and achieve the patient-set priorities.Conclusion: This study will provide valuable insights into the feasibility and acceptability of post-discharge support for hospitalised older adults within this local healthcare context. The findings will directly inform clinical practice and guide the development of a subsequent Phase II trial examining patient-reported outcomes and readmission rates in this vulnerable population. Future research should also focus on refining transitional care interventions to enhance adaptability and effectiveness across diverse healthcare environments.This study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), registration number ACTRN12624000795594.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12624000795594.