Optimal Comprehensive Geriatric Assessment in Hospital-to-Home Transitional Care for Older Patients: A Review of Concept and Evidence-Based Practices

Abstract

        A comprehensive geriatric assessment (CGA) during the transition from hospital to home is essential for identifying those at risk of hospital-acquired complications and readmission to the hospital. The assessment enables timely care planning and risk management through a multidisciplinary approach.

        This literature review sought to provide empirical evidence on CGA during transitional care from hospital to home. Literature was searched across five databases—CINAHL, PubMed, ScienceDirect, and Google Scholar—using the keywords "comprehensive geriatric assessment," "discharge plan," "older adults," and "transitional care." A total of 45 articles were identified, of which 19 were included in the analysis after excluding those that did not meet the objectives or lacked full-text access. Each article was independently reviewed and appraised by the authors. Seventeen studies were rated as level 1 evidence, while two were rated as level 2 and level 4 evidence, respectively. The extracted data were synthesized and presented collaboratively.

        Findings indicate that there is no standardized model for conducting comprehensive geriatric assessment during care transitions. Institutions may adopt or develop assessment tools tailored to their specific context. Nevertheless, it is recommended that assessments address all relevant domains, including health problems, physical health, mental and cognitive status, functional ability, and environmental factors. Assessments should be systematically scheduled from admission through discharge and extended to follow-up at home. Post-discharge monitoring may be conducted by healthcare providers through home visits or telehealth technologies, which can also facilitate the active participation of patients, caregivers, and community volunteers in the assessment process.