“…Multiple studies suggest that hospital-to-home care transitions for this population are fragmented and poorly coordinated, resulting in increased hospital readmission rates, adverse medical events, decreased patient satisfaction and safety, and increased caregiver burden [23][24][25][26][27][28][29][30][31]. Studies in Canada, the USA, and elsewhere have attributed these adverse outcomes to factors such as lack of patient knowledge about available community-based services resulting in suboptimal or delayed utilization of these services [31,32], conflicting plans of care and instructions from different providers [31,[33][34][35][36], medication errors [29-31, 37, 38], lack of timely follow-up with specialists and family physicians after hospital discharge [30,31,39], limited engagement of older adults and caregivers in care decisions [29,40] and preparation for self-care [30,37,38,[41][42][43], lack of support for family caregivers, poor communication and collaboration among providers within and across settings [29,30,44], lack of timely and adequate home-based support after hospital discharge [29,30], untreated or under-treated depressive symptoms [29,[45][46][47], inadequate community mental health supports [29], and having other unaddressed social and psychological needs during previous hospitalization…”