Transitioning to Care: Core Components and Outcomes of Transitional Care Programs for Older Adults

Transitions from hospital to home can be challenging for older adults with complex health needs and multiple chronic conditions. Transitional Care Programs (TCPs) aim to improve continuity of care, support recovery, and reduce adverse outcomes. This review examined the core components, outcomes, and factors influencing the effectiveness of TCPs for older adults. A systematic literature review was conducted using PubMed, CINAHL, Cochrane Library, and Scopus. Studies published in English from 2010 onward involving adults aged ≥ 65 years and evaluating hospital-to-home TCPs were included. Randomized controlled trials, cohort studies, and qualitative studies were considered. Two independent reviewers extracted study characteristics, intervention components, outcomes, and implementation factors. Of 42 records identified, 12 duplicates were removed, 22 full-text articles were assessed, and 15 studies were included. Common TCP components included patient-centred assessment, comprehensive discharge planning, care coordination, patient and family education, medication management, follow-up monitoring, home-care services, and multidisciplinary team involvement. Reported benefits included improved functional status, quality of life, patient satisfaction, and medication management, with reductions in hospital readmissions, emergency department use, and length of stay. Important gaps included limited reporting of intervention fidelity and dose, variation in intervention intensity and implementation across settings, insufficient integration of family caregivers into discharge planning and follow-up, and inconsistent outcome measurement. TCPs can facilitate safer and more effective transitions for older adults. Future models should strengthen family engagement, standardize intervention delivery and outcome measurement, and ensure continued post-discharge follow-up.