Post-Acute Care Transitions for Older Adults

Post‐acute care transitions encompass the movement of older patients from acute hospital settings to subsequent venues of care, such as skilled nursing facilities, inpatient rehabilitation, or home with community services. These transitions are critical junctures in the care continuum, during which coordination among multidisciplinary teams, effective information exchange, and patient and caregiver engagement determine outcomes. Older adults often present with multiple chronic conditions, cognitive impairment and polypharmacy, increasing vulnerability to adverse events, functional decline and unplanned readmissions. Successful transitions rely on standardised assessment tools, clear discharge plans, medication reconciliation and timely sharing of clinical information. Globally, health systems seek to optimise resource use by reducing avoidable hospital days and enhancing quality of life, while ensuring that care remains person-centred and addresses the social, psychological and physical needs of older adults.

Research from Nature Portfolio

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Post-Acute Care Transitions for Older Adults publication trend

The graph below shows the total number of articles in post-acute care transitions for older adults across all publications each year (not limited to Nature Index journals).

Technical terms

Post-acute care: Care provided after hospital discharge, including rehabilitation, skilled nursing or home services.

Skilled nursing facility (SNF): A healthcare setting offering 24-hour nursing care and therapy services following acute hospitalisation.

Transitional care: A set of time-limited services that ensure coordination and continuity of healthcare as patients transfer between settings.

Activities of daily living (ADLs): Core self-care tasks such as bathing, dressing and feeding used to assess functional status.

Polypharmacy: The concurrent use of multiple medications, often defined as five or more, which increases risk of adverse drug events.

References

1. Transitional care in skilled nursing facilities: a multiple case study. BMC Health Services Research (2016).
2. Information Sharing Practices Between US Hospitals and Skilled Nursing Facilities to Support Care Transitions. JAMA Network Open (2021).
3. The impact of facility-based transitional care programs on function and discharge destination for older adults with cognitive impairment: a systematic review. BMC Geriatrics (2022).