Management of care transition and hospital discharge

Expert Review


Current demographic and epidemiological trends highlight a growing task in surgical departments by elderly patients, characterized by high prevalence of comorbidity, complexity, and functional disability. Of consequence, discharge of an elderly patient must be considered in a new cultural perspective and should be imagined as a well-structured process starting from admission to surgical department and finishing with the patient discharge in a setting able to support her/him in the best possible way. The lack of a suitable discharge planning and of a proper transition program in the elderly subjects increases the risk of quick re-admission and may negatively affect the functional and the status quality of life of patients and caregivers. To reduce the risk of negative outcome it is essential a hospital organization dedicated to the discharge of frail older patients considering: (1) adequate attention to assess the comprehensive clinical/social/care conditions; (2) respect of the expectations of the patient and her/his relatives; (3) formalization of institutional roles or teams designated to the planning and coordination of discharge; (4) good knowledge of management programs of transitional care, and (5) strong communication/information ability in patients transition between hospital, home care and community settings.


Care continuity Comprehensive geriatric assessment Discharge planning Transitional care Community settings Hospital organization 



Discharge planning


Transitional care


Comprehensive geriatric assessment


Blaylock risk assessment screening score


Activities of daily living


American society of anesthesiologists


Compliance with ethical standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Statement of human rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Statement on the welfare of animals

This article does not contain any studies with animals performed by any of the authors.

Informed consent

For this type of study, formal consent is not required.


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Medical Sciences, Geriatric-Orthogeriatric Unit S. Anna HospitalUniversity of FerraraFerraraItaly
  2. 2.Department of Medical SciencesUniversity of FerraraFerraraItaly

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