Transitional rehabilitation care and patient care continuity as an advanced nursing practice.

OBJECTIVE: To analyze the needs and facilitating and hindering elements related to transitional rehabilitation care. METHODS: Integrative literature review oriented toward answering the question "What nursing interventions guarantee transitional rehabilitation care to dependent adult or elderly people when they return home after hospitalization?". RESULTS: The patients did not participate much in the planning of hospital discharge and decision-making when they had to return home. Informal caretakers reported that professionals showed detachment during hospitalization and delayed guiding instructions. Health professionals mentioned lack of time to offer this care modality as a difficulty. FINAL CONSIDERATIONS: Ensuring training, follow-up, and coordination between care levels is essential. Care integration can reduce hospital stay and the impact of post-discharge complications. Transitional care contributes to a sustainable health system, higher care quality, and client satisfaction.