Care Transition Strategies, Opportunities, and Challenges for Patients Following COVID-19 Hospitalization: An Integrative Review

Care transition is a strategy that aims to overcome the fragmentation of healthcare services, ensuring continuity of care. The review question was: What scientific evidence is available on care transition strategies for patients after hospitalization for COVID-19 and what are the opportunities and challenges of their implementation? Integrative literature review was guided by Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and carried out between March and June 2024 in the Medical Literature Analysis and Retrieval System Online, Web of Science, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, Literatura Latino-Americana e do Caribe em Ciências da Saúde , Cochrane Library, Scientific Electronic Library Online and Scopus databases, using Medical Subject Headings, Health Sciences Descriptors, and Entry Terms. Fourteen articles published between 2020 and 2023 were included, with 57% originating from the Americas, 28.6% using a qualitative approach, 78.6% addressing the transition from hospital to home, and 78.6% involving patients. The results were organized into four thematic categories: virtual care transition; patients’ and healthcare professionals’ experiences in care environments; patients’ needs after hospital discharge; and care transition assessment through Care Transition Measure (CTM-15). Care transition strategies, including teleconsultations, videoconferencing, telerehabilitation, and discharge guidance, can reduce complications and readmissions and improve patient satisfaction, but challenges such as early discharge, poor communication, lack of protocols, variability in care transition strategies, and discontinuity of care still persist. The results of this review highlight the importance of structured, patient-centered transition planning, integration of telehealth and remote monitoring, and the use of systematic assessment tools, such as the CTM-15, to optimize post-hospital care for COVID-19 survivors.