Stakeholder insights into hospital-home transitions for older adults in a decentralised health system: a qualitative study

Background Hospital-home transitions are critical points in the care trajectory for older adults, requiring alignment between clinical decision-making, communication, and home-based support to maintain care continuity. In decentralised health systems, where responsibilities are distributed across multiple providers, these transitions may be vulnerable to fragmentation. Although transitional care has been studied, little is known about how it unfolds in decentralised, mixed-provider systems, where accountability is distributed across providers. This study constitutes the contextual inquiry phase of a Medical Research Council-guided intervention development programme and explores how hospital-home transitions are experienced and enacted in a decentralised Swiss region. Methods We conducted a qualitative descriptive study in southern Switzerland involving 26 participants. Data were generated through two focus groups with hospital–based professionals ( n = 18) and seven semistructured interviews with community stakeholders. These included general practitioners, public and private home-care providers, self-employed nurses, one patient, and one family caregiver. Topic guides were informed by international discharge standards and Transitions theory constructs. Audio recordings were transcribed verbatim and analysed via reflexive thematic analysis, combining inductive coding with deductive sensitising concepts from Transitions theory. Reporting follows COREQ. Results Five interrelated themes described hospital-home transitions as fragile and often sustained through ad hoc support: (1) fragile communication pathways marked by inconsistent and person-dependent information flows; (2) medication safety as a systemic fault line, with frequent discrepancies between hospital and home regimens; (3) diffuse accountability and uneven bridging roles, whereby coordination relied on discretionary efforts; (4) families compensating for coordination gaps; and (5) practices that supported smoother transitions, including early discharge planning, proactive liaison roles, and structured information tools. Conclusions Across stakeholder groups, continuity of care was maintained through informal coordination by professionals and families. Strengthening hospital-home transitions may require more reliable discharge communication routines, clearer medication processes, and more structured involvement of family caregivers and community providers. These findings, drawn mainly from professional perspectives, can inform the co-design of transitional care improvements tailored to the local context. Trial registration Not applicable.