Transitional care for older people from hospital to home: a best practice implementation project

The objective of this implementation project was to promote evidence-based practice of transitional care for older people from hospital to home.

The transition following hospitalization is a critical period of health risk for older people and their family caregivers. Older people need to learn how to take care of themselves at home safely, and caregivers play an important role in caring for them both in hospital and at home.

A clinical audit was undertaken using evidence-based criteria regarding transitional care. Eight audit criteria that represented best-practice recommendations of transitional care for older people from hospital to home were used. A baseline audit was conducted, followed by the implementation of transitional care strategies, and the project was finalized with a follow-up audit to determine the change in practice.

Improvements in clinical practice were identified in relation to healthcare professional knowledge regarding transitional care, patient care needs during the transition and a multifaceted approach during the transition phase.

The project demonstrated positive changes in the transitional care for older people from hospital to home. A multifaceted approach, including patient-centered discharge instruction, telephone follow-up and family caregiver preparedness, is required for older adults to be successfully discharged from hospital to home.