The effectiveness of interventions on clinical and patient-reported outcomes in hospital-to-home transitions of older adults: a systematic review
Laura Maria Steiner, Selvedina Osmancevic, Sabine Hahn, Loris Bonetti, Sandra Zwakhalen
Abstract
The global ageing population presents growing challenges for health and social care systems, particularly during transitions from hospital to home for older adults. These high-risk periods are associated with functional decline, hospital readmissions, and reduced quality of life. This systematic review synthesised evidence from 25 randomised controlled trials (RCTs), involving 17,542 participants aged 65 and older, to evaluate the effectiveness of transitional care interventions. A comprehensive search of PubMed, CINAHL Complete, and Scopus was conducted for studies published between January 2013 and March 2024. Outcomes were categorised using the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy into four domains: clinical outcomes, life impact, resource use, and death/adverse events. Most interventions were multicomponent, combining structured discharge planning, caregiver involvement, follow-up, and home-based support, typically delivered by multidisciplinary teams. Interventions were frequently associated with improvements in functional status, mood, and nutritional outcomes, as well as modest reductions in hospital readmissions and emergency department visits in the short term. Few studies assessed outcomes beyond six months, and sustained effects were uncommon. Few interventions demonstrated effects on mortality or adverse events. Caregiver engagement, particularly involving informal caregivers, and early post-discharge follow-up emerged as key enablers of success. Due to considerable heterogeneity in intervention design and outcomes, findings were synthesised narratively. This review highlights the potential of personalised, interdisciplinary transitional care models tailored to the complex needs of older adults. Future research should prioritise long-term outcomes, patient-reported experiences, and the development of scalable, context-sensitive strategies, including digital tools and caregiver-inclusive approaches.