Digitally Supported Transitional Care Pathways for Older Adults: A Multi-Site Co-Design Study

During transitions from hospital to home, older adults are frequently affected by fragmented communication, limited coordination between levels of care, and insufficient post-discharge follow-up. Digital technologies, including remote patient monitoring (RPM), digital communication, and artificial intelligence (AI), offer opportunities to improve continuity of care. However, their integration needs to reflect the organizational and clinical contexts of different healthcare systems. This study presents the development and early implementation of digitally supported transitional care pathways wi

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