ArticleInternational journal of integrated care
Integrated Care Components in Transitional Care Models from Hospital to Home for Frail Older Adults: A Systematic Review.
Article in International journal of integrated care. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 35 papers, 5 of them syntheses that pooled it.
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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.
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Who cites it
35 citing papers in PubMed, 5 syntheses or guidelines pooled it, 51 citations in OpenAlex.
- Patient Engagement Interventions to Improve Medication Management of Older Patients Across Transitions of Care: A Mixed Methods Systematic Review.Journal of clinical nursing · 2026Pooled it
- Experiences with hospital-to-home transitions: perspectives from patients, family members and healthcare professionals. A systematic review and meta-synthesis of qualitative studies.Disability and rehabilitation · 2025Pooled it
- The Effectiveness of Nurse-Led Transition Care on Post-Discharge Outcomes of Adult Stroke Survivors: A Systematic Review and Meta-Analysis.Nursing open · 2025Pooled it
- Transitional care programs for older adults moving from hospital to home in Canada: A systematic review of text and opinion.PloS one · 2024Pooled it
- Facilitators and inhibitors in hospital-to-home transitional care for elderly patients with chronic diseases: A meta-synthesis of qualitative studies.Frontiers in public health · 2023Pooled it
- A Physiotherapy-Led Transition to Home Intervention for Older Adults Following Emergency Department Discharge: A Pilot Feasibility Randomised Controlled Trial (ED PLUS).Clinical interventions in aging · 2023Trial
- Adaptation Model for Patient and Caregiver Dyads in Hospital-to-Home Transition: Theory Development and Content Validation.Healthcare (Basel, Switzerland) · 2026Article
- The Mediation Role of Relatedness and Competence for Patient Activation: A Longitudinal Study of Older Adults with Chronic Illness.Healthcare (Basel, Switzerland) · 2026Article
- Article
- Evaluation of goal setting and behavior change training for transition care case managers using Kirkpatrick's Model.Translational behavioral medicine · 2026Article
- Perspectives of Nurses in the VA Coordinated Transitional Care (CTraC) Program: A Qualitative Study.Journal of the American Geriatrics Society · 2025Article
- 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
- A Multi-Method Study to Develop and Pilot Test an Interprofessional Transitional Care Model for Frail Older Adults - AdvantAGE.Journal of advanced nursing · 2025Article
- Health-related quality of life and patient experiences regarding care transitions in hospitalized older patients with chronic diseases.Scientific reports · 2025Article
- Opportunities for optimising care transitions of adults with multiple long-term conditions: a qualitative interview study.BMC geriatrics · 2025Article
- Exploring success in sub-acute hospital-to-home transitions for palliative patients: a descriptive qualitative study.BMC palliative care · 2025Article
- Older Adults' Experiences of Emergency Department Admission Decisions: A Qualitative Study in a Public Safety Net Hospital.Journal of general internal medicine · 2025Article
- Informing research design through patient and public involvement; patients and carers with lived experience post-hospital discharge and potential roles for general practice pharmacists.BMC research notes · 2025Article
- Article
- Models of Integrated Acute Care for Older Adult Inpatients That Incorporate Integrative Health: An Integrative Review.Journal of multidisciplinary healthcare · 2025Review
Corrections and comments
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Authors and funding
7 authors at 2 institutions in 2 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
Introduction: Frail older adults frequently experience transitions from hospital to home due to their complex care needs. Transitional care models (TCMs) are recommended to tackle adverse outcomes in frail patients. This review summarizes the use of integrated care components in addressing transitional care from hospital to home, provides an overview on reported outcomes and describes the impact of identified components on the outcomes hospital readmission and emergency department visit. Methods: This study is part of the European TRANS-SENIOR project. PubMed, CINAHL and Embase were searched for studies in English, German and Dutch that describe a TCM for frail older patients including both pre- and post-discharge components. Results: Seventeen studies, covering 15 TCMs were included. All TCMs describe a person-centred, tailored, pro-active and continuous transitional care service. Components like a small sized care team, intensive follow-up, shared decision making and informal caregiver involvement are likely to be associated with reduced hospital readmission and ED visits. Twenty-seven transitional care outcomes were reported: 19 service outcomes, six patient outcomes and two provider outcomes. Conclusion: Heterogeneity in content and outcomes complicates between-study comparison, yet several components were identified that improved care outcomes. Patient and provider outcomes should be included in future research.
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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.