PTOTRNSystematic ReviewRevista brasileira de enfermagem2025

Transitional Care for Patients with Amyotrophic Lateral Sclerosis to the Home: A Scoping Review.

Evelyn Silva de Sousa, Larissa Arielly Cunha da Silva, Renilly de Melo Paiva and 3 others

PMID 40802439

WHAT IT FOUND

People with ALS going home need individualized transition plans: multidisciplinary care, discharge planning, telehealth, medication administration support, and caregiver training.

This review mapped 7 studies, mostly expert opinion, so it shows what care looks like, not what works.

Key findings

01The final sample included seven publications.

02Mapped transitional care activities included daily living help, care planning, protocol development, telehealth, and communication between services.

03Three studies reported benefits in care organization and communication; four studies reported stress and caregiver burden.

STILL TO COME

How it was doneWhat they foundWhat it means for PTsWhat it means for OTsWhat it means for RNs

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What it does not show

Only seven publications were included, so the map is sparse. Six studies were classified as level 4 evidence and one as level 1, so most content is expert opinion. The review maps concepts and practices; it does not test whether transitional care improves patient outcomes. Full-text availability was limited to sources accessible through the CAPES portal via CAFe, which may exclude studies not available there. The search was run from February to May 2023, so later studies are not included.

Declared interests

The supplied article text does not include a conflicts or funding declaration; the publication metadata lists non-U.S. government research support.

The easy way to misread this

Do not conclude that these transitional care strategies improve patient outcomes. The review mapped seven publications, mostly level 4 evidence, and did not test effectiveness.

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