From Hospital to Home: Why Care Transitions Are a Patient-Safety Priority for Older People in Viet Nam
INTEGRATED CARE & CARE TRANSITIONS
From Hospital to Home: Why Care Transitions Are a Patient-Safety Priority for Older People in Viet Nam
INTEGRATED CARE & CARE TRANSITIONS
Last reviewed: October 2026
For many patients, leaving the hospital feels like the end of a difficult episode. The acute problem has improved, discharge criteria have been met, medications have been prescribed and the person is going home. From the hospital’s perspective, the episode may appear complete.
For an older person, however, discharge can mark the beginning of one of the most vulnerable parts of the care journey. The person may return home with new diagnoses, changed medications, reduced mobility, unresolved symptoms, rehabilitation needs or a different level of independence from before admission. Family members may suddenly become responsible for medicines, appointments, mobility, nutrition, personal care and warning signs they have never had to manage before. At the same time, the clinicians who know what happened in the hospital are no longer physically present, while the professionals responsible for what happens next may not yet have all the information they need.
This is why the move from hospital to home should not be treated simply as an administrative discharge process. It is also a patient-safety, continuity-of-care and system-coordination issue. WHO has long identified transitions between care settings as an important patient-safety concern. Its work on transitions of care notes that older people with complex needs may experience repeated transitions and can be particularly vulnerable to fragmented care, medication problems, communication failures and gaps in follow-up.
Discharge is an event. Transition is a process.
Hospital discharge and transitional care are related, but they are not the same thing. Discharge is a point in time: the patient formally leaves the hospital. Transitional care is broader. It concerns what happens before, during and after responsibility for care moves between settings, professionals and the patient or family.
A good discharge summary may be necessary, but it is not sufficient if the next provider does not receive it in time. Medication reconciliation matters, but the transition can still be unsafe if the patient does not understand which medicines were stopped, started or changed. A follow-up appointment may be booked, but the plan can still fail if the person deteriorates beforehand and no one knows whom to contact.
The same applies to function. An older patient may be clinically stable enough to leave the hospital while walking less well or requiring more assistance than before admission. If the discharge process does not identify what changed, what support will be available at home and who will reassess the person afterward, a clinically successful hospitalization may still be followed by a difficult or unsafe recovery.
A useful way to reframe the discharge decision is therefore to ask not only “Is this patient ready to leave the hospital?” but also “Is the next stage of care ready for this patient?” That shift turns discharge from an endpoint into part of a continuing care pathway.
Why older people can be particularly vulnerable
Age alone does not determine whether a transition will be difficult. Many older people remain independent and return home without major problems. Risk becomes more complex when aging intersects with multimorbidity, frailty, polypharmacy, cognitive or sensory impairment, functional limitations, social circumstances and dependence on others for care.
Hospitalization may also change a person’s baseline. Someone who walked independently and managed their own medications before admission may leave with weakness, a walking aid and a very different medication regimen. A person who experienced delirium may appear substantially better by discharge while still having fluctuating cognition. Someone successfully treated for pneumonia or heart failure may nevertheless need more support than before the illness.
These changes matter because care at home is very different from care in the hospital. In the hospital, staff, medicines, monitoring and escalation are readily available. At home, much of the day-to-day responsibility may shift to the older person or a family caregiver. Discharge planning therefore needs to consider not simply whether the acute illness has improved, but what the person can realistically manage once they leave the hospital.
Medication safety shows why transitions matter
Medication changes are common during hospitalization. Medicines may be stopped because of adverse effects, new treatment started, doses adjusted and short-term therapies added. By discharge, the medication regimen can look very different from the one the patient had before admission.
WHO identifies medication safety in transitions of care as one of the three priority areas of its Medication Without Harm initiative, alongside polypharmacy and high-risk situations. WHO specifically emphasizes structured processes, workforce capability, partnership with patients and families, better information and measurement as important elements of safer medication transitions.
Medication reconciliation is therefore important: the care team needs to establish what the person was taking before admission, what changed during hospitalization and what the intended regimen should be afterward. But reconciliation alone does not complete the safety task.
A systematic review published in Drugs & Aging in February 2026 examined 49 studies of strategies intended to maintain medication changes after older people left the hospital. Common approaches included providing discharge medication lists to patients or primary-care clinicians, medication counseling and medication reconciliation. Most interventions were multicomponent, and many involved multidisciplinary teams. About 68% of studies assessing continuity-related outcomes reported significant improvements, although improvements in clinical outcomes or health-service use were far less consistent.
The practical implication is straightforward. An accurate medication list matters, but someone also needs to know whether the older person or caregiver understands which medicines to take, which have been discontinued, why changes were made and what problems should trigger further advice. That is the difference between documenting medication changes and creating a safe medication transition.
Information and responsibility must travel with the person
Care can become unsafe even when every individual professional performs their own task correctly. A hospital may reduce an antihypertensive medicine because of hypotension, recommend rehabilitation because mobility has declined and request laboratory testing within a week. If the next clinician receives only part of that information, each original decision may have been appropriate while the overall pathway becomes fragmented.
Useful information transfer therefore needs to make the next actions clear. What happened during admission? Which problems remain active? What medications changed and why? Are results still pending? Has function changed? What follow-up is required, by whom and when? Which warning signs matter, and whom should the patient or family contact if something goes wrong?
The goal is not simply to send more information. A long discharge document that arrives late or buries the important actions can still fail both the next provider and the patient. What matters is timely, accurate and usable information.
Recent evidence strengthens this systems perspective. A systematic umbrella review published in March 2026 synthesized 18 reviews of patient safety during care transitions involving older people. Communication, discharge documentation and coordination were among the organizational risk factors identified, while commonly studied interventions included discharge planning, medication management, patient and family education, interdisciplinary collaboration and home-based follow-up. The authors emphasized that effective approaches are often multifaceted and need to be adapted to local context.
Caregivers are often part of the transition
Hospital-to-home pathways are sometimes designed as though the patient alone will carry out the discharge plan. In practice, families and other caregivers may arrange appointments, obtain medicines, assist with mobility and personal care, prepare meals, monitor symptoms and decide when deterioration requires medical attention.
That role becomes particularly important when an older person has cognitive impairment, reduced function or complex treatment needs. Caregivers therefore need more than a set of instructions. They may need to understand what has changed, what they are being asked to do, what is beyond their role and where help is available.
A 2026 mixed-methods systematic review examining family engagement in medication management during transitions of care found that collaborative information exchange and written information could support family involvement, while caregiver burden, poor communication and misalignment between families, older people and health systems could make that involvement more difficult. The review also highlighted the importance of multidisciplinary coordination and more family-centered approaches.
This does not mean families should become substitutes for professional services. It means that whenever successful implementation of a care plan depends on a caregiver, caregiver readiness is part of the safety and feasibility of that plan.
What does the broader evidence say?
The evidence supports transitional care as an important area for improvement, but it does not support one universal model.
A 2025 systematic review of 25 randomized trials involving 17,542 adults aged 65 and older found that hospital-to-home interventions were usually multicomponent, commonly combining structured discharge planning, caregiver involvement, follow-up and home-based support. Interventions were often associated with improvements in functional status, mood and nutrition, as well as modest short-term reductions in readmissions and emergency-department visits. However, intervention designs and outcomes varied substantially, few studies examined outcomes beyond six months and sustained effects were uncommon.
A separate meta-analysis of 49 randomized trials involving 25,566 patients with complex care needs found low-certainty evidence that multidisciplinary transitional-care interventions reduced readmissions, with a relative risk of 0.88. Effects on several other outcomes were less certain or variable, and the authors emphasized the importance of tailoring interventions to specific populations and contexts. PubMed
The 2026 umbrella review adds an organizational perspective: patient safety during transitions depends on interacting elements such as communication, discharge planning, medication management, coordination, interdisciplinary working, education and follow-up. Springer Link
Taken together, the evidence suggests that continuity needs to be deliberately designed, but the design should reflect the people being served, available resources and the health and care system in which it will operate. Copying a transition model from another setting without adaptation is unlikely to be enough.
A safe transition starts before discharge and continues at home
For an older person with complex needs, waiting until the day of discharge to consider what happens next can be too late. Planning can begin by understanding the pre-hospital baseline. How did the person walk before admission? Were they independent in daily activities? Who managed the medicines? Did they live alone? What family or community support was already available? Without this baseline, clinicians may fail to recognize how much function has changed during the hospital stay or how different life at home may now be.
Potential post-discharge needs can then be identified early enough to respond. These may include medication support, wound care, rehabilitation, nutrition, mobility equipment, caregiver education, primary-care follow-up, specialist review or social support. The goal is not to keep an older person in the hospital until every possible risk has disappeared. It is to make the transition planned rather than abrupt.
The first days at home also test whether the plan works in real life. Was the medication actually obtained? Can the patient manage it correctly? Has mobility deteriorated? Is the person eating and drinking adequately? Has confusion returned? Can the family provide the support that was assumed? Has follow-up actually been arranged, and are pending results being tracked?
There is no single follow-up interval that can be applied appropriately to every older person across different conditions and settings. Higher-risk patients may need earlier and more intensive contact, while others may require less. The more useful principle is that follow-up should reflect transition risk and individual need.
Viet Nam’s policy environment is changing
Hospital-to-home care is becoming increasingly relevant in Viet Nam because national policy is giving greater attention to older-person care beyond the hospital.
Decision No. 1116/QĐ-TTg, issued on 22 June 2026, amended the national Program for Health Care of Older Persons to 2030. Among its updated targets, by 2030, 90% of commune-level administrative areas are expected to have at least one older-person care club and at least one volunteer care team, while at least 20% are expected to pilot or develop day-care models. The decision also targets geriatric capacity in every province and centrally governed city and expands professional training and service models for older-person care.
A second important development is Decree No. 168/2026/NĐ-CP, issued on 15 May 2026 and effective from 1 July 2026. The decree provides detailed rules for older-person care at home and in the community under the Population Law. Home-care activities include providing knowledge and skills for care and prevention, early detection and care for some common conditions, support for physical and mental health and social connection, and assistance with activities of daily living.
The decree also recognizes older-person care clubs and community day-care points. A legally important distinction is that a community day-care point is a special model under the commune-level health station, has no separate legal-person status and does not perform medical examination or treatment activities. Its defined functions include care and prevention education, physical activity and support with activities of daily living.
That distinction matters for discharge planning. A hospital cannot simply write “community care” into a plan and assume that clinical monitoring, rehabilitation, medication management or medical treatment will automatically be available through a community day-care point. The capabilities of the receiving service, the responsibilities of each provider and the referral or escalation pathway still need to be understood.
These developments strengthen the home and community side of the care continuum, but the policies themselves do not constitute a standardized nationwide hospital-to-home transitional-care pathway. The implementation question therefore remains important: how should hospitals, primary care, rehabilitation, community services, older people and families connect in practice?
Community services only help if the interfaces work
Expanding services outside the hospital is important, but services alone do not create integrated care. A community program may be well designed yet receive little meaningful information about an older person’s recent hospitalization. A hospital may have a good discharge process but send the patient home expecting a service that is unavailable locally. Primary care may be expected to provide follow-up, but responsibility can remain unclear if there is no reliable mechanism for transferring information.
WHO’s second edition of the Integrated Care for Older People (ICOPE) handbook, published in September 2025, is relevant here. It supports person-centered assessment and care planning in primary care, including community settings, and describes practical pathways intended to be adapted to local context. It specifically addresses declines in intrinsic capacity, social-care and support needs, and the development of personalized care plans.
ICOPE should not be treated as a ready-made hospital discharge standard for Viet Nam. Its relevance is broader: it reinforces the principle that older-person care should continue across settings and that clinical, functional and support needs need to remain connected as circumstances change.
Hospital-to-home transition sits precisely at that interface between acute treatment and ongoing life.
What should organizations measure?
Readmission is often treated as the headline outcome of transitional care, but it should not become the only measure of success. Some readmissions are clinically appropriate and unavoidable. Conversely, a poor transition may never result in readmission. An older person may experience medication confusion, delayed follow-up, loss of function or substantial caregiver burden while never returning to the hospital.
A more useful measurement approach considers both the transition process and what happens afterward. Depending on the organization and patient population, this might include the completeness and timeliness of discharge information, medication reconciliation, identification of functional change, caregiver preparedness, completion of planned follow-up, post-discharge medication discrepancies, emergency visits, readmissions, patient and caregiver experience and functional outcomes.
Not every organization needs to measure everything. A pilot can begin with a small set of meaningful indicators linked to the main risks in its own pathway. The practical question is simple: did the transition work for the patient after they left us?
Care transitions are also a governance issue
Care transitions are sometimes treated primarily as the responsibility of a discharge nurse, case manager or attending physician. But recurring failures at the hospital-home boundary usually point to broader organizational issues. The 2026 umbrella review specifically identified communication, discharge documentation and coordination as organizational patient-safety risks, while common improvement strategies involved discharge planning, medication management, standardized communication, interdisciplinary collaboration, education and home-based follow-up.
That makes several governance questions difficult to avoid. Who owns the hospital-to-home pathway? Which patients need enhanced transitional care? What information must be transferred? Who verifies medication changes? Who assesses whether the patient or caregiver can manage the plan? Who tracks pending results? Who confirms that the next provider has received the information? What happens when planned follow-up cannot be arranged?
If the answers depend largely on individual initiative, the quality of the transition is likely to vary among clinicians and departments. Transitional care therefore belongs within quality governance and patient-safety systems, with defined responsibilities, risk-based processes, escalation routes, measurement and mechanisms for learning when transitions fail.
A readmission, medication error or post-discharge complaint should not automatically be interpreted as proof that someone made a mistake. It may, however, be an opportunity to examine whether the system created avoidable risk at the boundary between hospital and home.
Not every older person needs the same transition
Age-friendly care should not turn older age into a reason for unnecessary intervention. A healthy, independent 68-year-old leaving the hospital after a straightforward procedure may need little more than clear information and routine follow-up. An 88-year-old living alone with frailty, cognitive impairment, multiple medications and newly reduced mobility may require a very different transition.
The objective is therefore not to build the most elaborate pathway for every older patient. It is to identify who needs what level of support, based on clinical complexity, function, cognition, medication burden, social circumstances, caregiver availability and the resources that actually exist after discharge.
WHO’s work on transitions of care similarly emphasizes factors beyond the primary diagnosis, including cognition, functional status, the home environment, availability of caregivers, access to medicines and services, and transportation.
For Viet Nam, the practical implication is that transitional care should be risk-based, person-centered and feasible within the local care environment.
Quality should cross the hospital door
A hospital may provide excellent clinical treatment, infection prevention and medication management during admission and still lose part of that benefit if the transition home is poorly coordinated.
The patient-safety principles used inside the hospital should therefore extend to the boundaries of care. Information should remain accurate. Responsibilities should remain clear. Medication changes should be understandable. Deterioration should have an escalation route. Changes in function should not disappear from view simply because the patient has crossed the hospital door.
This becomes particularly important for older people because recovery frequently continues after discharge and may increasingly depend on family, primary care, rehabilitation, community support and, for some people, long-term care.
From the perspective of organizations, the hospital, home and community are different settings. From the perspective of the older person and family, they are one continuing care journey.
Viet Nam is expanding its policy attention to care at home and in the community. The next challenge is not simply to establish more services on either side of the hospital door, but to make the connections between those services reliable.
A useful question for every hospital caring for older people is therefore not only “Was this patient safely discharged?” It is also “Did we help create a safe transition to what comes next?”
That is why hospital-to-home care transitions should be understood not as an administrative detail, but as a patient-safety, quality and integrated-care priority for an aging Viet Nam.
References
World Health Organization. Transitions of Care: Technical Series on Safer Primary Care. Geneva: WHO; 2016. World Health Organization
World Health Organization. Medication Safety in Transitions of Care. Geneva: WHO; 2019. World Health Organization
Johnstone KJR, Hilmer SN, Lo S, et al. Bridging the Gap: Systematic Review of Strategies to Facilitate Post-Discharge Continuity of In-Hospital Medication Changes in Older Adults. Drugs & Aging. 2026;43:137–152. Springer Link
Wagenaar B, Schouten B, Ket JCF, et al. Addressing organizational risk factors and interventions during transitions of care for older patients: a systematic umbrella review. BMC Health Services Research. 2026;26:530. Springer Link
Deery C, Marconi G, Ottosen K, et al. Family engagement in the medication management of older adults during transitions of care: A mixed methods systematic review. International Journal of Nursing Studies. 2026;174:105305. ScienceDirect
Steiner LM, Osmancevic S, Hahn S, Bonetti L, Zwakhalen S. The effectiveness of interventions on clinical and patient-reported outcomes in hospital-to-home transitions of older adults: a systematic review. European Journal of Ageing. 2025;22:58. Springer Link
Collet R, van Grootel J, van Dongen J, et al. The Impact of Multidisciplinary Transitional Care Interventions for Complex Care Needs: A Systematic Review and Meta-Analysis. The Gerontologist. 2025;65(6):gnaf088. PubMed
World Health Organization. Integrated Care for Older People (ICOPE): Guidance for Person-Centred Assessment and Pathways in Primary Care. 2nd ed. Geneva: WHO; 2025. World Health Organization
Prime Minister of Viet Nam. Decision No. 1116/QĐ-TTg amending Decision No. 1579/QĐ-TTg approving the Program for Health Care of Older Persons to 2030. 22 June 2026. Công Báo Điện Tử Việt Nam
Government of Viet Nam. Decree No. 168/2026/NĐ-CP detailing a number of articles and measures for implementation of the Law on Population. 15 May 2026; effective 1 July 2026.