Transition care

Key points

  • Successful transition care services should incorporate multidisciplinary care teams, proactively support those at risk of delayed discharge, consider individuals with cognitive impairment, and involve family carers.
  • Transition care services should consider developing and integrating educational resources that explain the recovery process, prepare individuals for what to expect on returning home, and allow for improved communication and goal setting.
  • Appropriate technology should be integrated into transition care services to improve knowledge dissemination, communication, access to care, and discharge planning.

Transition care programs (TCPs) provide services that support older adults returning from hospital to their own home. Some individuals receive TCPs in residential aged care facilities to support a return home. These packages are time-limited (up to 12 weeks), personalised to the individual, and provide restorative care. [1] Transition care often consists of nursing, occupational therapy, physiotherapy, and other support services such as cleaning and shopping assistance. [2] These services aim to restore function and enable older adults to live as independently as possible in their own homes, whilst preventing hospital readmission and premature admittance to residential aged care facilities. [3]

This evidence theme on transition care is a summary of one of the key topics identified by a scoping review of rehabilitation, reablement, and restorative care research. If you need more information on this topic, try using the PubMed search below.

Overall, each review reported specific, yet different research aims with some similarities. Three reviews examined qualitative evidence to determine:

  • the perspectives of patients with hip fractures using transition care [4]
  • experiences of patients with dementia using transition care [5]
  • how active involvement in care affected the experience of transition from one environment to another. [6]

Three reviews focused on the outcome measures used in transition care services [5, 7, 8] and a further three investigated interventions provided in transition care. [9-11] The remaining reviews examined:

  • the extent to which community participation was considered in transition care services [1]
  • the specific roles of rehabilitation professionals in transition care [10]
  • the adaptation of the oldest old returning home following discharge from intensive care [12] 
  • the importance of discharge preparation and continuity of care. [13]

The reviews identified that:

  • Experiences of transition care could be improved with better information provision to service users on what to expect when returning home, [1] an increased understanding of care provider roles, and a more organised discharge planning process. [4]
  • Technologies such as video conferencing might be used to reduce barriers to care such as distance, allow planning and delivery of services, and improve communication and care between service providers. [4, 14]
  • Transition care for older adults is an integral service that can reduce rehospitalisation rates. These services need to be delivered by professionals who plan, deliver, direct care, carry out regular assessments, and communicate effectively with older adults and family carers. [10, 13]
  • Older adults discharged from intensive care units require individualised and continued care following discharge home to allow them to regain their independence and prevent rehospitalisation. [12]
  • Barriers to accessing transition care include the readiness of healthcare services to deliver care, poor process planning, and older adults’ knowledge and uptake of supportive services. [9]
  • Transition care services should support older adults to maintain the leisure and social activities they deem important. Continued participation can improve mobility, reduce falls, and increase community involvement and health-related quality of life. [1]
  • Following the completion of transition care programs, it is unclear whether older adults regained their previous levels of mobility and independence. [7] Further evidence is required to determine whether continued support is required following the cessation of transition care packages.
  • Transition care services commonly provided education and goal-orientated exercise and social support interventions addressing the older persons’ mobility, rehabilitation, and activities of daily living. Treatments focus on transfers, stair climbing, strength and balance exercises, and the provision of mobility aids. [8, 11]
  • The implementation of transition care for older adults living with dementia is not well understood and raises clinical concerns for the focus of person-centred, individualised, high-quality care whilst long-term support is being arranged. [5]
  • Individuals should consider the difficulties faced by older adults returning home from the hospital and be involved in discharge and transition care planning at the earliest possible opportunity.
  • Support the independence of older adults and promote individuals to retake ownership of their personal care and activities of daily living.
  • Organisations can develop and integrate additional resources that detail the recovery process, prepare individuals for what to expect on returning home, and allow for improved communication of support services available to older adults transitioning between care settings. [1, 4]
  • Assess the needs of service users before, during, and after a care transition to deliver effective patient and family-centred care across a range of settings [4] and consider the development of transition care plans for each long-term patient whilst still in the hospital to aid better recovery and rehabilitation following hospital discharge. [12]
  • Design and provide transition care services that incorporate multidisciplinary care teams, proactively support those at risk of delayed discharge, consider individuals with cognitive impairment, and involve care partners. [8]
  • Support staff to recognise all states of patient involvement as valid, reflect on how their behaviours can influence involvement, and understand how these can impact patient safety and experience. [6]
  • Support research to identify which aspects of transition care contribute to a successful discharge. [7]
  1. Gough C, Baker N, Weber H, Lewis LK, Barr C, Maeder A, et al. Integrating community participation in the transition of older adults from hospital to home: A scoping review. Disabil Rehabil. 2021:1-13.
  2. Australian Government Department of Health and Aged Care. Transition Care Programme Guidelines [Internet]. Canberra: DoHAC; 2022 [cited 2023 Jun 30]. Available from:
  3. Australian Institute of Health and Welfare. Older people leaving hospital: A statistical overview of the Transition Care Program in 2008-09 [Internet]. Canberra: AIHW; 2011 [cited 2023 Jun 23]. Available from:
  4. Asif M, Cadel L, Kuluski K, Everall AC, Guilcher SJT. Patient and caregiver experiences on care transitions for adults with a hip fracture: A scoping review. Disabil Rehabil. 2020;42(24):3549-58.
  5. Richardson A, et a. Stakeholder perspectives of care for people living with dementia moving from hospital to care facilities in the community: A systematic review. BMC Geriatr. 2019;19(202).
  6. Murray J, et a. How older people enact care involvement during the transition from hospital to home: A systematic review and model. Health Expect. 2019;22(5):883-93.
  7. Hang JA, Naseri C, Francis-Coad J, Jacques A, Waldron N, Knuckey R, et al. Effectiveness of facility-based transition care on health-related outcomes for older adults: A systematic review and meta-analysis. Int J Older People Nurs. 2021;16(6):e12408.
  8. McGilton KS, Vellani S, Krassikova A, Robertson S, Irwin C, Cumal A, et al. Understanding transitional care programs for older adults who experience delayed discharge: A scoping review. BMC Geriatr. 2021;21(1):210.
  9. Fakha A, et a. A myriad of factors influencing the implementation of transitional care innovations: A scoping review. Implement Sci. 2021;16:21.
  10. Kalu ME, Maximos M, Sengiad S, Dal Bello-Haas V. The role of rehabilitation professionals in care transitions for older adults: A scoping review. Phys Occup Ther Geriatr. 2019;37(3):123-50.
  11. O’Donnell R, et a. The effectiveness of transition interventions to support older patients from hospital to home: A systematic scoping review. J Appl Gerontol. 2020.
  12. da Cruz Pessoa LS, Chaves Pedreira L, Pereira Santos JL, Lemos de Souza M, Pereira Goés R, Santana Lopes AO. Adaptation of the elderly at home after intensive unit discharge. Journal of Nursing UFPE / Revista de Enfermagem UFPE. 2019;13:994-1002.
  13. de Oliva Menezes TM, Barreto de Oliveira AL, Barbosa Santos L, Araújo de Freitas R, Chaves Pedreira L, Cardoso Bastos Veras SM. Hospital transition care for the elderly: An integrative review. Rev Bras Enferm. 2019;72:294-301.
  14. Glenny C, Stolee P, Sheiban L, Jaglal S. Communicating during care transitions for older hip fracture patients: Family caregiver and health care provider's perspectives. Int J Integr Care. 2013;13(4):e044-e.
Spacing Top
Spacing Bottom

Connect to PubMed evidence

This PubMed topic search is limited to home care and residential aged care settings. You can choose to view all citations or citations to articles available free of charge.

Selected resources

Transition care for older people leaving hospital

This report from the Australian Institute of Health and Welfare provides information about the transition care program, the providers, the characteristics of the recipients and the outcomes of change.

Transition Care Program Guidelines

The guidelines from the Department of Health explain the Australian Government’s policy context and operational requirements for the Transition Care Programme, including the clarification of responsibilities of the approved providers under the Aged Care Act 1997, and the Aged Care Principles which govern the operation of the programme.