ArticleJournal of the American Geriatrics Society2021
A scoping review of interventions for older adults transitioning from hospital to home.
Article in Journal of the American Geriatrics Society, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 48 papers, 2 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
48 citing papers in PubMed, 2 syntheses or guidelines pooled it.
- Prevalence of and Risk Factors for Drug-Related Readmissions in Older Adults: A Systematic Review and Meta-Analysis.Drugs & aging · 2024Pooled it
- Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes: A Systematic Review and Network Meta-Analysis.JAMA network open · 2023Pooled it
- Clinical outcomes and cost-utility analysis of comprehensive geriatric assessment models in hospitalized frail older patients in Thailand.BMC geriatrics · 2026Trial
- Preparedness for care transitions to home and acute care use of skilled nursing facility patients.BMC geriatrics · 2025Trial
- Connect-Home transitional care from skilled nursing facilities to home: A stepped wedge, cluster randomized trial.Journal of the American Geriatrics Society · 2023Trial
- Legislative compliance in coordinated care transitions: a mixed-method study of healthcare professionals' documentation and older adults' experiences.International journal of qualitative studies on health and well-being · 2026Article
- Safe homecoming intervention after hospital discharge: a retrospective cohort study of mortality and readmission among patients 75 years or older in Sweden.BMC geriatrics · 2026Observational
- Adaptation Model for Patient and Caregiver Dyads in Hospital-to-Home Transition: Theory Development and Content Validation.Healthcare (Basel, Switzerland) · 2026Article
- Exploring Patient and Caregiver Work and Continuity of Care During Hospital-to-Home Transitions of Care in the Canadian Context.Health expectations : an international journal of public participation in health care and health policy · 2026Article
- Experience, barriers and facilitators of discharge readiness in patients with acute pancreatitis: a descriptive qualitative study.BMJ open · 2026Article
- Position, Responsibilities and Practice Interventions Relevant for Danish Transitional Care Nurses to Perform During Discharge of Older People: Delphi Survey.Journal of advanced nursing · 2026Article
- Days at Home After Serious Health Events Among Community-Living Older Persons.Journal of the American Geriatrics Society · 2026Article
- Perceived Needs of Individuals with Frailty and Their Caregivers During the Transition from Hospital to Home: Protocol of a Qualitative Systematic Review and Evidence Synthesis.Nursing reports (Pavia, Italy) · 2026Article
- A Qualitative Exploratory Study of Families' Experiences and Recommended Strategies to Improve the Medication Management of Older Adults During Transitions of Care.Drug, healthcare and patient safety · 2026Article
- The effectiveness of interventions on clinical and patient-reported outcomes in hospital-to-home transitions of older adults: a systematic review.European journal of ageing · 2025Review
- Implementing pharmacist-led home medicines reviews within fracture liaison services for better post-fracture care: a qualitative study of patient and practitioner experience.Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA · 2025Article
- Factors Influencing Outcomes of a Telehealth-Based Physical Activity Program in Older Veterans Postdischarge.Federal practitioner : for the health care professionals of the VA, DoD, and PHS · 2025Article
- A Nurse-Led Cross-Sectoral Home-Based Follow-Up Visit for Older Patients Discharged From the Hospital: A Practice Research Project.Nursing open · 2025Article
- Interventions for adult survivors discharged from the intensive care unit: a scoping review.BMJ open · 2025Article
- Exploring caregiver perspectives on health service delivery priorities for individuals with complex care needs: a qualitative descriptive study.BMC health services research · 2025Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
5 authors.
Funding
Abstract
BACKGROUND/
objectivesOlder adults are at high risk for adverse outcomes as they transition from hospital to home. Transitional care interventions primarily focus on care coordination and medication management and may miss key components. The objective of this study is to examine the current scope of hospital-to-home transitional care interventions that impact health-related outcomes and to examine other key components including engagement by older adults and their caregivers.
designScoping review.
methodsEligible articles focused on hospital transition to home intervention, measured primary outcomes posthospitalization, used randomized controlled trial designs, and included primarily adults aged 60 years and older. Articles included in this review were reviewed in full and all data were extracted that related to study objective, setting, population, sample, intervention, primary and secondary outcomes, and main results.
resultsFive hundred sixty-seven records were identified by title. Forty-four articles were deemed eligible and included. Most common transitional care intervention components were care continuity and coordination, medication management, symptom recognition, and self-management. Few studies reported a focus on caregiver needs or goals. Common modes of intervention delivery included by phone, in person while the patient was hospitalized, and in person in the community following hospital discharge. The most common outcomes were readmission and mortality.
conclusionTo improve outcomes beyond healthcare utilization, a paradigm shift is required in the design and study of care transition interventions. Future interventions should explore methods or novel interventions for caregiver engagement; leverage an interdisciplinary team or care coordination hub with engagement from underrepresented specialties such as social work and occupational therapy; and examine opportunities for interventions designed specifically to address older adult and caregiver-reported needs and their well-being.
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What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.