Background Discharge planning is a routine feature of health systems in many countries that
aims to reduce delayed discharge from hospital, and improve the co‐ordination of services …

There is currently a lack of evidence on the optimal strategy to support patient recovery after
critical illness. Previous research has largely focussed on rehabilitation interventions which …

Background hospital level healthcare in the home guided by comprehensive geriatric
assessment (CGA) might provide a less costly alternative to hospitalisation for older people …

Across the world, life expectancy is increasing. However, the years of life gained do not
always correspond to healthy life years, potentially leading to an increase in frailty. Given the …

Background Transitional care implies the transfer of patients within or across care settings in
a seamless and safe way. For frail, older patients with complex health issues, high-quality …

Background There is growing evidence about the role of nurses in patient outcomes in
several healthcare settings. However, there is still a lack of evidence about the transitional …

Background Many hospitalized older adults cannot be discharged because they lack the
health and social support to meet their post-acute care needs. Transitional care programs …

Background Clinical uncertainty is inherent for people with frailty and multimorbidity.
Depleted physiological reserves increase vulnerability to a decline in health and adverse …

Older adult patients account for 70% of all hospitalized patients in Japan, and intermediate
care based on patient-centered care (PCC) that ensures continuity and quality of care at the …

Background Adults increasingly live and die with chronic progressive conditions into
advanced age. Many live with multimorbidity and an uncertain illness trajectory with points of …