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原文摘要

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 within the TransCare project. Care pathways were analyzed and redesigned across three pilot sites in Italy, Romania, and Norway. Existing clinical and organizational processes were mapped to identify challenges and opportunities for improvement. Technology-augmented pathway matrices were developed to integrate RPM, digital communication tools, and AI-supported analytics across the stages of assessment, hospitalization, discharge, and post-discharge follow-up. The pathways were iteratively refined through a co-design process involving healthcare professionals, patients, caregivers, and technical partners. Early implementation experiences were subsequently analyzed across the three sites. Common challenges included fragmented communication and poor care coordination, particularly during discharge and post-discharge follow-up. However, the underlying cause and required solutions differed across the pilot sites, reflecting variations in patient profiles, healthcare organizations, available resources, and digital maturity.