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Informal Caregivers in Transitional Hospital-to Home Care for Older People:

Addressing Gaps in Pre-Discharge Collaboration for Enhanced Patient Outcomes

Published Date: 11.10.2025

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Theme: Carer health and wellbeing

Sub-theme: Physical health

Caregivers Older people Discussion paper

Verification Statement

This publication / resource is hosted on a publicly available external link. If the full text is not publicly accessible, summary points are included and a contact method for the author(s) is provided, where available.

The summary information presented is based on content submitted by an author or other user
, along with publicly available information about the publication / resource added by the Carer Knowledge Exchange team.

All content is reviewed, edited and approved by the Carer Knowledge Exchange team, in line with our Submission Guidelines.


To report an issue or request a change, please complete our Feedback Form.

 

Theme: Carer health and wellbeing

Sub-theme: Physical health

View Publication Caregivers Older people Discussion paper

Verification Statement

This publication / resource is hosted on a publicly available external link. If the full text is not publicly accessible, summary points are included and a contact method for the author(s) is provided, where available.

The summary information presented is based on content submitted by an author or other user
, along with publicly available information about the publication / resource added by the Carer Knowledge Exchange team.

All content is reviewed, edited and approved by the Carer Knowledge Exchange team, in line with our Submission Guidelines.


To report an issue or request a change, please complete our Feedback Form.

 

Informal Caregivers in Transitional Hospital-to Home Care for Older People:

Addressing Gaps in Pre-Discharge Collaboration for Enhanced Patient Outcomes

Published Date: 11.10.2025

  • Author/ Authors

    Filipa Pereira , Catherine Bolduc, Pauline Melly, Virginie Renggli

  • Suggested citation (APA 7th edition)

    Pereira, F., Bolduc, C., Melly, P., & Renggli, V. (2025). Informal Caregivers in Transitional Hospital-to-Home Care for Older people: Addressing Gaps in Pre-Discharge Collaboration for enhanced patient outcomes. Patient Preference and Adherence, Volume 19, 3159–3167. https://doi.org/10.2147/ppa.s532419

Long Summary

The article highlights the critical role of informal caregivers (ICs) in hospital-to-home transitions for older adults, emphasizing their contributions to patient safety, emotional support and continuity of care. Despite this, ICs often face exclusion from discharge planning, poor communication, and lack of formal recognition, which can lead to adverse outcomes and increased caregiver burden. The paper calls for systemic reforms, including integrating ICs into hospital protocols, improving communication and leveraging technology to support their needs. Evidence-based models like the Transitional Care Model suggest that structured collaboration with ICs enhances care quality, reduces readmissions and promotes better long-term health outcomes.

    Key Messages for Carers


  • Carers are essential partners in ensuring safe and effective transitions from hospital to home. It emphasises the importance of carers being actively involved in discharge planning, understanding medication and follow-up care and maintaining clear communication with healthcare providers. By staying informed and engaged, carers can help prevent complications, support better recovery and reduce stress for themselves and the patient. The article also suggests using available tools and resources to manage care effectively and highlights that their participation significantly improves health outcomes.

  • Key Messages for Policy Makers


  • Integrating informal caregivers (ICs) into hospital discharge planning is essential for improving patient outcomes and reducing readmissions. Policies should mandate structured communication between healthcare teams and ICs, provide training resources, and leverage technology for seamless transitions. Recognizing ICs as partners in care ensures continuity, enhances safety and reduces systemic costs. Evidence-based models like the Transitional Care Model demonstrate that collaborative approaches lead to better health outcomes and lower caregiver burden.

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The Carer Knowledge Exchange is led by Carers NSW and proudly funded by the NSW Government. It was established as a partnership between Carers NSW and the Institute for Public Policy and Governance (IPPG) at the University of Technology Sydney from 2021-2024. We acknowledge Aboriginal and Torres Strait Islander peoples as the First Australians and Traditional Custodians of the lands where we live, learn and work.