KEY POINTS

• Interventions that seek to improve the transition between hospital and other settings include: comprehensive geriatric assessments; specialist dementia / delirium unit; short-term early discharge home care and rehabilitation packages; early supported discharge with multidisciplinary community care; multi-professional palliative care.
• Each has been linked to some positive outcomes – although for specialist delirium/ dementia unit and for multi-professional palliative care outcomes referred to small changes in mood, satisfaction or symptom control rather than to changes in health-related quality of life.
• Early supported discharge programmes that include a rehabilitation-focused community care package are likely to be cost-effective from a combined health and social care perspective. The evidence refers to older people and people with stroke.
• Comprehensive geriatric assessment and short-term rehabilitation provided to older people in hospital units may be cost-effective from a hospital perspective, but the wider impacts are unclear.
• Multi-professional palliative care might be cost-effective; evidence refers to people with multiple sclerosis and people with breathlessness; there might cost savings for people with multiple sclerosis due to reductions in hospital and primary care.
• A specialist delirium/ dementia unit was not cost-effective based on health-related quality of life but might importantly improve experiences of people using it and their carers.
• Various national initiatives have been recently implemented to support development of innovative services to integrate care between hospitals and other settings.