Introduction

Transitional care is a form of healthcare coordination that is provided to patients prior to discharge and continued beyond inpatient care [1], allowing the maintenance of therapeutic relationships that are established during inpatient stays [2]. Healthcare professionals support patients before and beyond the inpatient stay by addressing care needs before discharge and following-up with those needs in the community setting, therefore allowing continuity of care [2]. This includes clinical assessment of patient’s healthcare needs and goals, creating care plans, planning and monitoring care and responding to changes in status [3]. Transitional care professionals provide patients with information about available services and guidance, and help patients receive services by linkage, referrals and follow-ups [4]. As such, transitional care plays a critical role in ensuring safe and effective transitions between care settings, particularly for populations with complex and ongoing needs.

Transitional care interventions highlighted in the literature include profession-oriented approaches such as education and training, organizational interventions (including roles like transition nurses, discharge protocols, discharge planning, medication reconciliation, standardized discharge letters, and electronic tools), and interventions focused on patients and their families, such as raising patient awareness, empowerment, and providing discharge support [5]. Various transitional care interventions aimed at ensuring coordinated and continuous healthcare during care transitions have been tested and proven effective in reducing hospital readmissions, shortening hospital stays, and enhancing quality of life and patient satisfaction [6,7]. However, much of this evidence has focused on general medicine populations, with comparatively less attention paid to the mental health (MH) needs of older adults during care transitions.

Transitional care is often provided by allied healthcare (AHC) professionals such as Social Workers (SW) and Occupational Therapists (OT), leading to smoother adjustments, fewer unmet needs [8] upon discharge, and improved functional outcomes [9]. This multidisciplinary support was found to be especially beneficial for persons living with co-occurring MH needs, as it reduces the likelihood of adverse events that may occur during transitions [10]. Despite the recognized value of AHC professionals in transitional care, limited clarity remains regarding which AHC roles are involved, how they are implemented, and the specific functions they serve for older adults with MH needs during transitions in care.

Older adults with MH conditions such as disturbances in cognition, emotional regulation, or behavior [11], experience physical, emotional, and social strains as a result of their illnesses, as well as by navigating through an often unfamiliar and frequently fragmented healthcare system [12]. Their MH needs may include prevention, early identification, treatment, rehabilitation, and ongoing supports related to MH symptoms, substance use, cognitive or emotional difficulties, and the social determinants that influence mental well-being [13–15]. MH conditions are complex and layered; there is a no one-size-fits all treatment, and they often involve a variety of specialists and care providers [16]. This is a result of the high comorbidity rates of physical health, MH, and substance use issues these patients experience, and an abundance of treatment options. Unfortunately, there is often insufficient cohesion between providers and facilities that comprise the MH care system [17,18]. Corresponding care systems can be geographically distanced, funded by different entities, and care providers may have knowledge of and/or comfort in a specific realm and little interaction with other providers. Additionally, there is a need of sequence in some MH treatments, as certain factors must be addressed in order to target other concerns [17], and a need for efficient communication between professionals focusing on physical healthcare and those focusing on MH [18]. Furthermore, MH symptoms can be overshadowed by chronic illnesses, preventing proper care by MH professionals [19–21].

MH patients could have poorer access to health services – including preventive measures, treatment, and care – compared to the general population. Some patients with MH needs have difficulty taking advantage of available healthcare services and therefore receive poor follow-up for their chronic medical conditions [22]. Indeed, in a qualitative study, interviewed participants with MH concerns emphasized the essential role of accessible healthcare services in maintaining a stable and meaningful life in their homes [4]. Therefore, individuals with MH needs often need help navigating the healthcare system and might lack information about available services [18]. These barriers highlight the importance of targeted transitional care approaches that explicitly address MH-related needs and system navigation challenges for older adults.

In general, older adults encounter more barriers to successful transitions of care due to higher medical burden and comorbidities, cognitive impairment, and/or frequent polypharmacy [23,24]. Older adults with multiple chronic conditions are more likely to experience depressive symptoms than older adults without these conditions [25], and frequent transitions between hospital and home. These transitions are often poorly coordinated and fragmented, resulting in increased readmission rates, adverse medical events, decreased patient satisfaction and safety, and increased caregiver burden [26]. Furthermore, older adults are disproportionately affected by transitions among and within hospital-based psychiatric and medical settings [23]. Understanding which older adults with MH needs are most vulnerable during transitions and the types of support they would require is essential to improve transitional care outcomes. A pilot quality improvement study indicated that care transitions to an acute medical setting from a psychiatric hospital might be more frequent in the geriatric population than in the other segments of the adult population. Not surprisingly, geriatric patients were overall more medically frail, took more home medications, and experienced longer hospital stays [23]. Therefore, older adults with MH needs are even at more risk for miscommunication in healthcare settings, duplication of services, medical errors and readmission [27].

The current scoping review focuses on transitional care provided to older adults with MH needs. Several knowledge synthesis projects assessed the delivery model and the efficacy of transitional care for older adults with MH needs, such as examining the implementation characteristics in transitional care programs for people living with dementia (PWD) and their caregivers [28], and the appropriateness of such programs for specific healthcare transitions [29]. However, little is known about integrating AHC professionals into transitional care to meet the specific MH needs of older adults. Specifically, there is limited synthesized evidence addressing (1) which older adults with MH needs require transitional care support, (2) the type of role AHC professionals play in supporting these transitions, and (3) they key lessons that can be learned from current implementation efforts.

To address these gaps, this scoping review examines the literature on the implementation of AHC professionals in the field, drawing primarily on studies focused on PWD to provide insights that may also apply to individuals with other MH needs. This review could inform policy and guide interventions to optimize the role of AHC professionals, subsequently improving care, patient well-being and future research on optimizing transitional care for this growing and vulnerable population.

Methods

Search selection

This scoping review includes articles focusing on transitional care programs for older adults with MH needs or the caregivers of older adults with MH needs undergoing care transition. Studies were deemed relevant if they satisfied the following inclusion criteria: (i) published from January 2010 to June 2025, (ii) written in English, (iii) full-text articles available, (iv) and the focus of the article was to address the role of AHC professionals (e.g., OT/PT/SW) in meeting the MH needs of older adults (aged 55 or older) across care transitions. There were no exclusion criteria based on geographic origin; however, review articles were excluded to ensure findings were drawn directly from primary research [33]. Articles describing transitional care programs for older adults with neurodevelopmental or neurological conditions such as autism, stroke, and traumatic brain injury were also excluded as their care pathways usually focus on acute, rehabilitative, or developmental services rather than MH care [34,35]. Three reviewers, ECNW, RS and MA, conducted the study selection, with two reviewers screening each article at every stage (title and abstract screening, as well as full-text). The first author, MM, resolved any discrepancies. The review process was conducted using the Covidence software [36]. Outlines the search and selection process.

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Fig 1. PRISMA [37].

https://doi.org/10.1371/journal.pone.0346032.g001

Results

The search identified 8,385 peer-reviewed articles. After applying the inclusion and exclusion criteria, 14 peer-reviewed articles were selected for this review (n = 14; see Fig 1). Details of the included articles are presented in Tables 1 and 2. Among the reported studies, five used quantitative designs [39,42,48,50,51], two used a qualitative design [44,43], and seven employed mixed-methods approaches [40,41,45–47,49,52]. Five studies used randomized control trials, while six studies conducted semi structured interviews and focus groups. The studies were conducted in the United States (n = 11), Australia (n = 2), and Sweden (n = 1). Study participants where either caregivers of persons with dementia (PWD) [39,45–47,52], PWD or cognitive impairment [42,44,48,49,50], caregivers and PWD dyads [40,41], older adults [51,49] and veterans [43].

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Table 1. Characteristics of included studies.

https://doi.org/10.1371/journal.pone.0346032.t001

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Table 2. Intervention delivery characteristics.

https://doi.org/10.1371/journal.pone.0346032.t002

Discussion

The aim of the present scoping review was to describe the literature on the integration of AHC professionals in transitional care for older adults with MH needs. Overall, this appears to be an under-studied topic, with only 14 identified studies meeting our inclusion criteria. Importantly, the majority of the studies appear to have focused on PWD, with very few focused on other MH concerns in older adults. It should be noted that original intent of this scoping review was not to explore this issue in PWD per se, but studies that included this population were included since PWD frequently experience co-occurring MH issues, such as depression and anxiety [53]. Depression is also a significant risk factor for developing dementia [54]. Some psychiatric conditions are intrinsic to the dementia phenotype, while others, such as major depression, schizophrenia, apathy, and irritability, may precede its onset. Many of these psychiatric disorders can also accelerate dementia progression by increasing distress and disability [55]. Therefore, including dementia within a MH framework provides a more comprehensive understanding of the complex needs of the older adult population, as dementia symptoms often overlap with broader MH challenges.

With regards to points of transition, most of the studies were focused on helping older adults transition back to the community. A noted long-term concern with community transitions for older adults are emotional concerns [56], in that this process is viewed as quite stressful. Follow-up call by psychologists were perceived as beneficial for caregivers’ confidence, coping and self-efficacy [47], as well as an effective mechanism for addressing the unmet MH needs of veterans at risk for suicide [43]. There is also evidence supporting both the efficacy and cost-effectiveness of phone follow-ups for supporting transitions in care for patients [57], and has been used to support MH follow-up [58]. Although psychologists may not be cost-effective within some contexts since they are typically more specialized and not funded by the public health system, further work exploring the use of AHC professionals to do follow-ups to meet MH needs during care transitions is worth further investigation.

With regards to transitions to another institutional setting, such as residential care or long-term care, older adults may experience ‘relocation stress’ [59,60], which is used to describe the MH impact of this type of change. In this instance, older adults may face increased confusion, anxiety, depression, and loneliness during the transition. For those with cognitive impairments, adapting to a new environment can worsen existing challenges, leading to disorientation and social difficulties [61]. Assimilation into long-term care often takes weeks to months and interdisciplinary teams play a vital role in ensuring smooth and supportive transitions for both residents and families [61].

As caregivers often become de facto coordinators during high-stress care transitions (e.g., liaising with facilities, monitoring quality, and managing family roles), transitional care was found to improve their readiness, coping, and communication capacity [52,46], an often under-recognized coordination pathway in dementia care [52], which may indirectly support more stable placements and fewer crises that trigger acute care use.

Although we only identified 14 studies that met our inclusion criteria, there was a diverse range of AHC providing MH supports to older adults and family members. In some studies, AHC with more extensive training in MH management, such as psychologists, counsellors and SW were used to support transitions. However, other AHC, such as OTs, are also well-suited for supporting MH transitions, and have direct competencies in MH as part of their clinical training [62]. As a result, OTs have been identified as a profession that may be particularly well-suited to support transitions in care [63], and further work exploring their contributions to MH transitions for the older adult population is warranted.

Other AHCs identified included PTs, paramedics, and pharmacists, which are professions that are not primarily focused on MH per se, but have the capacity and ability to provide MH supports as indicated by some of the included studies. For instance, Shah et al., 2022 [48] demonstrated that employing paramedic coaches effectively reduced ED revisits among cognitively impaired older adults. These coaches utilized strategies like motivational interviewing to enhance patients’ self-management skills.

The reviewed literature suggests that transitional care could be strengthened by clarifying responsibility for key transition tasks, rather than assuming coordination occurs organically across teams, with SWs and case managers leading discharge coordination and community linkage, and nurses focusing on education and medication safety [49]. Improvements are also likely when medication management is treated as a shared, cross-setting process embedded in team-based care, rather than a standalone discharge activity [50]. As medication management is a common failure point during transitions [50], embedding pharmacists in transition workflows can strengthen cross-setting continuity of medication decisions such as reconciliation, deprescribing, and monitoring plans. In dementia-related transitions, coaching and counselling roles that support caregivers appear to enhance communication, confidence, and informal coordination with providers [52]. Finally, adapting transitional care models to explicitly include cognitively impaired patients may reduce avoidable acute care use and better address the needs of high-risk groups [48].

Several studies have noted that older adults are high users of EDs; [64] many of whom who experience MH challenges [65]. As such, interventions aimed at helping older adults with MH concerns has the potential to lead to more appropriate healthcare utilization, and potential better supports as they transition to the community. As well, there is evidence for training programs in elevating the capacity for MH supports in pharmacists [66], which holds potential as a point of care for MH support in older adults, especially given the high rates of polypharmacy in this population [67]. Regardless, some studies noted a team-based approach, where AHCs worked collaboratively to address MH issues, and likely can address a range of physical, mental and social issues that could negatively impact transitions to other settings.

As noted above, our review identified a number of studies related to meeting the needs of PWD as they either transition back to the community from hospital or to residential or long-term care. A recent systematic review examined navigation programs for PWD and their caregivers [28] indicating diverse providers and offered services, varying in their implementation and targeted outcomes. A consensus about best practices in transitional care is important, since PWD have unique, illness specific challenges such as progressive decline and stigma. Without consensus, programs risk inconsistencies in addressing these unique needs [68].

Conclusions

The reviewed studies highlight the need for scalable, evidence-based interventions targeting both patients with MH needs and their caregivers, with a focus on long-term impacts and diverse populations. This scoping review enhances our understanding of the current state of transitional care and offers insights on optimizing programs for older adults with MH needs.

Supporting information