Assessment of Patient Functioning in Transitional Care: An Observational Study

Transitional care requires effective coordination between hospital and community services to ensure continuity of care and appropriate post-acute rehabilitation pathways. In this context, physiotherapists may contribute to discharge planning through standardized assessment of patients' functional status and rehabilitation needs.

This study aimed to assess patients' functional status at hospital discharge, investigate variability in post-acute care allocation across three hospitals, and explore the contribution of physiotherapist-led functional assessment to hospital-to-community transitional care pathways.

A retrospective observational study was conducted within the Local Health Authority ASL Roma 2 and included patients from three hospitals (Sant'Eugenio, Sandro Pertini, and CTO Andrea Alesini) who required activation of a post-acute care pathway and were assessed by physiotherapists within the Hospital Operations Team (TOH) during 2024. Functional, cognitive, and health-related quality-of-life status were assessed using standardized instruments, including the Barthel Index, Modified Rankin Scale (mRS), Mini-Mental State Examination (MMSE), and EQ-5D-5L. Between-hospital differences were assessed using non-parametric tests, while the association between hospital of origin and discharge setting was evaluated using the chi-square test and Cramér's V.

A total of 2,314 patients were included. Home care (ADI) was the most frequent discharge setting in Sant'Eugenio and Sandro Pertini, whereas intensive rehabilitation Code 56) predominated at CTO. Hospital of origin was significantly associated with discharge setting (χ²=893.34, p<0.001; Cramér's V=0.456), indicating substantial between-hospital variability in post-acute care allocation. Significant differences were also observed in age, length of stay, functional independence, cognitive status, and health-related quality of life (all p<0.001). Between-hospital heterogeneity was particularly pronounced for MMSE (ε²=0.365) and EQ-5D-5L index (ε²=0.260). Correlation analyses further showed significant relationships among functional, cognitive, and demographic measures.

Post-acute care allocation differed substantially across the three hospitals and was associated with differences in patient case-mix and hospital-specific organizational characteristics. Physiotherapist-led functional assessment may provide relevant multidimensional information to support discharge planning and the identification of appropriate post-acute rehabilitation pathways. These findings support the integration of physiotherapists within multidisciplinary transitional care teams, while further multicenter studies are needed to determine their specific impact on discharge appropriateness and long-term outcomes.