Geriatric transition care between acute hospital and residential healthcare settings: scoping review of current models and proposed conceptual framework

Abstract

Background: Population ageing and the increasing complexity of care pathways make transitions from hospital to residential healthcare facilities a critical phase for continuity of care. Inadequate management may result in clinical errors, repeated hospitalisations, and increased healthcare costs. The lack of standardised models and limited understanding of transitional care pathways highlight the need for further investigation of existing approaches.

Objectives: This scoping review aims to identify and map geriatric transitional care models described in the literature, focusing on their main characteristics, the professionals involved, and their potential applicability within the Italian National Health Service.

Methods: A scoping review was conducted according to the guidelines of the Joanna Briggs Institute and Prisma-ScR. The bibliographic search, carried out on Medline, ScienceDirect and Web of Science, identified 2107 articles. After removing duplicates and screening against predefined inclusion and exclusion criteria, seven studies were included.

Results: Across the seven studies, twelve transitional care projects were identified. Most models adopted a multidisciplinary, nurse-centred approach with active involvement of patients and family caregivers. Advanced Practice Nurses or equivalent expert nurses played a central role in care coordination, medication reconciliation, and post-discharge follow-up, contributing to reduced hospital readmissions and improved patient satisfaction.

Conclusions: Existing models suggest that multidisciplinary transitional care, supported by expert nurses, can enhance continuity and quality of care for older adults transferred to residential facilities. The conceptual framework derived from this mapping should be interpreted as a hypothesis‑generating synthesis to guide local adaptation and piloting in Italy, particularly by strengthening the role and competencies of Family and Community Nurses.

Keywords: Care; Nurse; Nursing process; Quality of nursing care; Transitional care; Transitional care model.