Goals of older adults transitioning from hospital to home in the community

This study examined 1) goals of older adults discharged from hospital to home in the community; 2) if goals changed during a short-term, community-based hospital-to-home program providing rehabilitation services.

Adults ≥ 60 years recently discharged from hospital and participating in the program recorded goals at baseline and discharge, completing the Patient Specific Functional Scale (PSFS). Goals were mapped to the International Classification of Functioning, Disability and Health (ICF). Pre- and post-program PSFS scores were analysed for change.

Thirty-eight percent of goals recorded at baseline were mapped as Body Functions, and 61.9% were mapped as Activities and Participation, with Mobility mapped goals most common (60.6%), followed by goals mapped as Domestic Life (21.2%). Of the goals mapped as Body Functions, 60.7% were mapped as Neuromusculoskeletal & Movement Functions. A statistically significant increase in PSFS scores from baseline to discharge was found for goals mapped to Activities and Participation and Body Functions domains, with the exception of those mapped to the Self-care domain.

Older adult participants had a variety of goals, including goals that did not pertain to physical function. The need for continued rehabilitation services and supports was highlighted by PSFS scores at program discharge.