• acute care discharge;
  • discharge planning;
  • transitional care;
  • transitions of care;
  • wicked problems


The aim of this review is to synthesize the current body of knowledge concerning transitional care for patients 65 years of age and older moving from the acute care setting to home.


Transitional care is a timely topic as hospital days of care decrease whereas patient needs grow more complex as a result of aging populations.


This review considers evidence-based research as well as reports, case studies and literature reviews related to transitional care. International articles are included.

Key issues

The authors explore transitional care through the lens of wicked problems; problems that appear seemingly intractable and are characterized by inter-related dilemmas, contradictory agendas, and multi-layered societal, economic and political influences. Outcome measures of success, barriers to achieving successful transitional care and effectiveness of interventions are investigated.


While the literature offers specific strategies that positively affect transitional care, there are few strategies that do not negatively affect an alternate agenda. Conscientious leaders should consider transitional care in the context of its wicked nature in order to achieve optimal patient care.


Stakeholders include: hospital administrators, nurse leaders, direct-care nurses, acute care and primary care clinicians, patients, caregivers, community agencies, health sciences educators and insurers.