Experiences with hospital-to-home transitions: perspectives from patients, family members and healthcare professionals. A systematic review and meta-synthesis of qualitative studies.
J W M van Grootel, R J Collet, J M van Dongen and 6 others
PMID 39101687WHAT IT FOUND
Patients and families struggle with discharge because they don't know who to call, get overwhelmed by bad information, and feel abandoned.
Professionals lack time and clear roles. Success relies on early planning, knowing exactly who coordinates care, and providing simple, timely support rather than just handing over paperwork.
Key findings
01A major barrier is ambiguity over responsibility; patients and staff often do not know who is coordinating care after discharge, leading to frustration and gaps in support.
02Patients frequently feel overwhelmed by information delivered all at once, or receive discharge letters that are unclear, incorrect, or arrive too late, causing them to miss critical details.
03Early planning of discharge and clear identification of who is responsible for coordination were the main facilitators for successful hospital-to-home transitions.
STILL TO COME
How it was doneWhat they foundWhat it means for PTsWhat it means for OTsWhat it means for SLPs
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What it does not show
The review excluded studies on monodisciplinary interventions (e.g., nurse-only phone calls), so it does not report on those specific models. Family caregivers' perspectives were often combined with patients' in the original studies, making it hard to isolate their specific needs. Non-Western countries were underrepresented, so findings may not apply to all healthcare systems. Many included studies were of moderate or fair quality, lacking details on researcher-participant relationships or data analysis rigor.
Declared interests
The authors declared no conflicts of interest. The study was not funded by a commercial entity.
The easy way to misread this
Do not interpret the lack of significant evidence for specific interventions as evidence that interventions don't work; this review synthesizes experiences and barriers, not efficacy. It identifies what patients and professionals need, but does not prove that any specific program successfully meets those needs.