{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T05:00:17Z","timestamp":1785387617526,"version":"3.55.0"},"reference-count":124,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T00:00:00Z","timestamp":1785196800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Med. Sci.","Medical Sciences"],"abstract":"<jats:p>Background: Returning home after neurological hospitalization, rehabilitation, or specialist care transfers responsibility to patients, caregivers, and community services. We mapped mechanisms and gaps across dementia\/Alzheimer\u2019s disease and related dementias (ADRD), Parkinson\u2019s disease (PD), multiple sclerosis (MS), and amyotrophic lateral sclerosis (ALS). Methods: Following JBI guidance and PRISMA-ScR, eligibility was derived using population\u2013concept\u2013context. We included empirical reports involving adults with a target condition, a post-discharge, return-home, rehabilitation, telehealth, caregiver, treatment, respiratory, or palliative continuity component, and post-transition patient, caregiver, service, safety, rehabilitation, equity, or implementation outcomes. Five databases were searched through to 11 May 2026. Two reviewers independently screened records; charting and classification were verified by R.S.C., A.C., and A.Q. Results: Of 24,417 records, 69 reports were included: Dementia\/ADRD, 28; PD, 10; MS, 9; and ALS, 22. Eighteen were core transition reports (26.1%), 14 return-home\/community re-entry reports (20.3%), 16 adjacent continuity reports (23.2%), and 21 companion\/secondary reports (30.4%). Dementia\/ADRD provided discharge-anchored evidence; PD and MS mapped functional carry-over; ALS mapped adjacent respiratory, telehealth, and palliative continuity. Conclusions: The main contribution is an operational cross-disease framework separating direct discharge, return-home, adjacent-continuity, and companion evidence while linking mechanisms to disease-specific pathways. This framework maps disease-specific functions, not comparative effectiveness. The proposed frameworks are author-derived and hypothesis-generating. Future studies should use explicit anchors, standardized outcomes, longer follow-up, and equity-sensitive implementation measures addressing caregiver workload, digital access, feasibility, and sustainability. They inform testable, context-sensitive intervention designs for future neurological transition-care research and practice.<\/jats:p>","DOI":"10.3390\/medsci14040445","type":"journal-article","created":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T13:07:33Z","timestamp":1785244053000},"page":"445","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Hospital-to-Home Neurological Transition Care: A Scoping Review Across Selected Chronic Neurological Disorders"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8566-3166","authenticated-orcid":false,"given":"Rocco Salvatore","family":"Calabr\u00f2","sequence":"first","affiliation":[{"name":"IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-5012-4425","authenticated-orcid":false,"given":"Andrea","family":"Calderone","sequence":"additional","affiliation":[{"name":"IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniele","family":"Ravi","sequence":"additional","affiliation":[{"name":"Department of Mathematics, Computer Science, Physics and Earth Sciences (MIFT), University of Messina, 98166 Messina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carmelo","family":"Galip\u00f2","sequence":"additional","affiliation":[{"name":"Department of Mathematics, Computer Science, Physics and Earth Sciences (MIFT), University of Messina, 98166 Messina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Felicita","family":"Crupi","sequence":"additional","affiliation":[{"name":"IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Angelo","family":"Quartarone","sequence":"additional","affiliation":[{"name":"IRCCS Centro Neurolesi Bonino Pulejo, 98124 Messina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Ding, C., Wu, Y., Chen, X., Chen, Y., Wu, Z., Lin, Z., Kang, D., Fang, W., and Chen, F. (2022). Global, regional, and national burden and attributable risk factors of neurological disorders: The Global Burden of Disease study 1990\u20132019. Front. Public Health, 10.","DOI":"10.3389\/fpubh.2022.952161"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"556","DOI":"10.1046\/j.1532-5415.2003.51186.x","article-title":"Improving the quality of transitional care for persons with complex care needs","volume":"51","author":"Coleman","year":"2003","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"533","DOI":"10.7326\/0003-4819-141-7-200410050-00009","article-title":"Lost in transition: Challenges and opportunities for improving the quality of transitional care","volume":"141","author":"Coleman","year":"2004","journal-title":"Ann. Intern. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"746","DOI":"10.1377\/hlthaff.2011.0041","article-title":"The care span: The importance of transitional care in achieving health reform","volume":"30","author":"Naylor","year":"2011","journal-title":"Health Aff."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"433","DOI":"10.7326\/0003-4819-158-5-201303051-00011","article-title":"Hospital-initiated transitional care interventions as a patient safety strategy: A systematic review","volume":"158","author":"Rennke","year":"2013","journal-title":"Ann. Intern. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"471","DOI":"10.1146\/annurev-med-022613-090415","article-title":"Reducing hospital readmission rates: Current strategies and future directions","volume":"65","author":"Kripalani","year":"2014","journal-title":"Annu. Rev. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1001\/jamaneurol.2017.3299","article-title":"The Parkinson Pandemic-A Call to Action","volume":"75","author":"Dorsey","year":"2018","journal-title":"JAMA Neurol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2284","DOI":"10.1016\/S0140-6736(21)00218-X","article-title":"Parkinson\u2019s disease","volume":"397","author":"Bloem","year":"2021","journal-title":"Lancet"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1002\/mds.23449","article-title":"Clinical problems in the hospitalized Parkinson\u2019s disease patient: Systematic review","volume":"26","author":"Gerlach","year":"2011","journal-title":"Mov. Disord."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"623","DOI":"10.1016\/S1474-4422(20)30064-8","article-title":"Integrated and patient-centred management of Parkinson\u2019s disease: A network model for reshaping chronic neurological care","volume":"19","author":"Bloem","year":"2020","journal-title":"Lancet Neurol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"565","DOI":"10.1001\/jamaneurol.2013.123","article-title":"Randomized controlled clinical trial of \u201cvirtual house calls\u201d for Parkinson disease","volume":"70","author":"Dorsey","year":"2013","journal-title":"JAMA Neurol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1152","DOI":"10.1212\/WNL.0000000000004357","article-title":"Connect.Parkinson Investigators. National randomized controlled trial of virtual house calls for Parkinson disease","volume":"89","author":"Beck","year":"2017","journal-title":"Neurology"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"572","DOI":"10.1016\/S0140-6736(24)01296-0","article-title":"Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission","volume":"404","author":"Livingston","year":"2024","journal-title":"Lancet"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1111\/ajag.12205","article-title":"Research in hospital discharge procedures addresses gaps in care continuity in the community, but leaves gaping holes for people with dementia: A review of the literature","volume":"34","author":"Chenoweth","year":"2015","journal-title":"Australas. J. Ageing"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"317","DOI":"10.2217\/nmt.15.23","article-title":"Systematic review of planned care transitions for persons with dementia","volume":"5","author":"Ray","year":"2015","journal-title":"Neurodegener. Dis. Manag."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1371","DOI":"10.1007\/s11606-020-06442-5","article-title":"Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: A Systematic Review","volume":"36","author":"Sawan","year":"2021","journal-title":"J. Gen. Intern. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1622","DOI":"10.1016\/S0140-6736(18)30481-1","article-title":"Multiple sclerosis","volume":"391","author":"Thompson","year":"2018","journal-title":"Lancet"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1816","DOI":"10.1177\/1352458520970841","article-title":"Rising prevalence of multiple sclerosis worldwide: Insights from the Atlas of MS, third edition","volume":"26","author":"Walton","year":"2020","journal-title":"Mult. Scler."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"353","DOI":"10.1016\/j.apmr.2016.04.016","article-title":"Rehabilitation in Multiple Sclerosis: A Systematic Review of Systematic Reviews","volume":"98","author":"Khan","year":"2017","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_20","first-page":"CD012732","article-title":"Rehabilitation for people with multiple sclerosis: An overview of Cochrane Reviews","volume":"1","author":"Amatya","year":"2019","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1212\/WNL.52.1.50","article-title":"Inpatient rehabilitation in multiple sclerosis: Do the benefits carry over into the community?","volume":"52","author":"Freeman","year":"1999","journal-title":"Neurology"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1136\/jnnp.73.3.250","article-title":"Home based management in multiple sclerosis: Results of a randomised controlled trial","volume":"73","author":"Pozzilli","year":"2002","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"427","DOI":"10.1080\/09638280802062553","article-title":"A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation","volume":"31","author":"Kairy","year":"2009","journal-title":"Disabil. Rehabil."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Flachenecker, P., Bures, A.K., Gawlik, A., Weiland, A.C., Kuld, S., Gusowski, K., Streber, R., Pfeifer, K., and Tallner, A. (2020). Efficacy of an Internet-Based Program to Promote Physical Activity and Exercise after Inpatient Rehabilitation in Persons with Multiple Sclerosis: A Randomized, Single-Blind, Controlled Study. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17124544"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"266","DOI":"10.7224\/1537-2073.2023-038","article-title":"Telecoaching of Individuals with Multiple Sclerosis After Inpatient Multidisciplinary Rehabilitation: The Danish MS Hospitals Rehabilitation Study","volume":"26","author":"Boesen","year":"2024","journal-title":"Int. J. MS Care"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1080\/1364557032000119616","article-title":"Scoping studies: Towards a methodological framework","volume":"8","author":"Arksey","year":"2005","journal-title":"Int. J. Soc. Res. Methodol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1186\/1748-5908-5-69","article-title":"Scoping studies: Advancing the methodology","volume":"5","author":"Levac","year":"2010","journal-title":"Implement Sci."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1097\/XEB.0000000000000050","article-title":"Guidance for conducting systematic scoping reviews","volume":"13","author":"Peters","year":"2015","journal-title":"Int. J. Evid. Based Healthc."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"467","DOI":"10.7326\/M18-0850","article-title":"PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation","volume":"169","author":"Tricco","year":"2018","journal-title":"Ann. Intern. Med."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Munn, Z., Peters, M.D.J., Stern, C., Tufanaru, C., McArthur, A., and Aromataris, E. (2018). Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med. Res. Methodol., 18.","DOI":"10.1186\/s12874-018-0611-x"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2119","DOI":"10.11124\/JBIES-20-00167","article-title":"Updated methodological guidance for the conduct of scoping reviews","volume":"18","author":"Peters","year":"2020","journal-title":"JBI Evid. Synth."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"953","DOI":"10.11124\/JBIES-21-00242","article-title":"Best practice guidance and reporting items for the development of scoping review protocols","volume":"20","author":"Peters","year":"2022","journal-title":"JBI Evid. Synth."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1016\/j.jclinepi.2016.01.021","article-title":"PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Statement","volume":"75","author":"McGowan","year":"2016","journal-title":"J. Clin. Epidemiol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"520","DOI":"10.11124\/JBIES-22-00123","article-title":"Recommendations for the extraction, analysis, and presentation of results in scoping reviews","volume":"21","author":"Pollock","year":"2023","journal-title":"JBI Evid. Synth."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"A12-3","DOI":"10.7326\/ACPJC-1995-123-3-A12","article-title":"The well-built clinical question: A key to evidence-based decisions","volume":"123","author":"Richardson","year":"1995","journal-title":"ACP J. Club"},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Schardt, C., Adams, M.B., Owens, T., Keitz, S., and Fontelo, P. (2007). Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med. Inf. Decis. Mak., 7.","DOI":"10.1186\/1472-6947-7-16"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"240","DOI":"10.3163\/1536-5050.104.3.014","article-title":"De-duplication of database search results for systematic reviews in EndNote","volume":"104","author":"Bramer","year":"2016","journal-title":"J. Med. Libr. Assoc."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1186\/s13643-020-01542-z","article-title":"PRISMA-S: An extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews","volume":"10","author":"Rethlefsen","year":"2021","journal-title":"Syst. Rev."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1093\/hsw\/24.4.249","article-title":"Adequacy of discharge plans and rehospitalization among hospitalized dementia patients","volume":"24","author":"Cummings","year":"1999","journal-title":"Health Soc. Work"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1131","DOI":"10.1002\/gps.3932","article-title":"A follow-up intervention in severely demented patients after discharge from a special Alzheimer acute care unit: Impact on early emergency room re-hospitalization rate","volume":"28","author":"Villars","year":"2013","journal-title":"Int. J. Geriatr. Psychiatry"},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Kable, A., Chenoweth, L., Pond, D., and Hullick, C. (2015). Health professional perspectives on systems failures in transitional care for patients with dementia and their carers: A qualitative descriptive study. BMC Health Serv. Res., 15.","DOI":"10.1186\/s12913-015-1227-z"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"203","DOI":"10.2217\/nmt.15.10","article-title":"Testing family-centered, function-focused care in hospitalized persons with dementia","volume":"5","author":"Boltz","year":"2015","journal-title":"Neurodegener. Dis. Manag."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1764","DOI":"10.1177\/1471301217728845","article-title":"An evaluation of discharge documentation for people with dementia discharged home from hospital: A cross-sectional pilot study","volume":"18","author":"Kable","year":"2019","journal-title":"Dementia"},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Bruce, R., Murdoch, W., Kable, A., Palazzi, K., Hullick, C., Pond, D., Oldmeadow, C., Searles, A., Fullerton, A., and Fraser, S. (2020). Evaluation of carer strain and carer coping with medications for people with dementia after discharge: Results from the SMS Dementia Study. Healthcare, 8.","DOI":"10.3390\/healthcare8030248"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"519","DOI":"10.1016\/j.jamda.2019.09.012","article-title":"Dementia severity associated with increased risk of potentially preventable readmissions during home health care","volume":"21","author":"Knox","year":"2020","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1009","DOI":"10.1016\/j.apmr.2019.12.021","article-title":"Function and caregiver support associated with readmissions during home health for individuals with dementia","volume":"101","author":"Knox","year":"2020","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1252","DOI":"10.1111\/jep.13551","article-title":"Caregivers\u2019 experiences of medication management advice for people living with dementia at discharge","volume":"27","author":"Sawan","year":"2021","journal-title":"J. Eval. Clin. Pract."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"15333175221129384","DOI":"10.1177\/15333175221129384","article-title":"Association of dementia severity and caregiver support with early discharge from home health","volume":"37","author":"Knox","year":"2022","journal-title":"Am. J. Alzheimers Dis. Other Demen"},{"key":"ref_50","first-page":"e12341","article-title":"Home health utilization association with discharge to community for people with dementia","volume":"8","author":"Knox","year":"2022","journal-title":"Alzheimers Dement"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"1486","DOI":"10.1016\/j.jamda.2022.06.021","article-title":"Unique care needs of people with dementia and their caregivers during transitions from skilled nursing facilities to home and assisted living: A qualitative study","volume":"23","author":"Toles","year":"2022","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1016\/j.gerinurse.2022.09.016","article-title":"Adapting the Connect-Home transitional care intervention for the unique needs of people with dementia and their caregivers: A feasibility study","volume":"48","author":"Toles","year":"2022","journal-title":"Geriatr. Nurs."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1016\/j.gerinurse.2023.03.002","article-title":"Caregivers\u2019 experience with Tele-Savvy Caregiver Program post-hospitalization","volume":"51","author":"Kovaleva","year":"2023","journal-title":"Geriatr. Nurs."},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"Du Preez, J., Celenza, A., Etherton-Beer, C., Moffat, P., Campbell, E., and Arendts, G. (2023). Caring for persons with dementia: A qualitative study of the needs of carers following care recipient discharge from hospital. BMC Palliat. Care, 22.","DOI":"10.1186\/s12904-023-01322-1"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"101132","DOI":"10.1016\/j.jaging.2023.101132","article-title":"Seeing the day-to-day situation: A grounded theory of how persons living with dementia and their family caregivers experience the hospital to home transition and beyond","volume":"65","author":"Saragosa","year":"2023","journal-title":"J. Aging Stud."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1111\/1475-6773.14059","article-title":"Post-acute care transitions and outcomes among Medicare beneficiaries with dementia: Associations with race\/ethnicity and dual status","volume":"58","author":"Yan","year":"2023","journal-title":"Health Serv. Res."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"igad083","DOI":"10.1093\/geroni\/igad083","article-title":"Testing an intervention to improve posthospital outcomes in persons living with dementia and their family care partners","volume":"7","author":"Boltz","year":"2023","journal-title":"Innov. Aging"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"1100","DOI":"10.1080\/13607863.2024.2304551","article-title":"Behavioral and psychological symptoms of dementia and adverse patient outcomes post-hospitalization","volume":"28","author":"Berish","year":"2024","journal-title":"Aging Ment. Health"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"973","DOI":"10.1080\/13607863.2024.2423889","article-title":"The association of physical resilience and post-discharge adverse events among older adults with dementia","volume":"29","author":"Drazich","year":"2025","journal-title":"Aging Ment. Health"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"e087231","DOI":"10.1136\/bmjopen-2024-087231","article-title":"Needs of family caregivers of hospitalised adults with dementia during care transitions: A qualitative study in a US Department of Veterans Affairs Hospital","volume":"14","author":"Horstman","year":"2024","journal-title":"BMJ Open"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1519\/JPT.0000000000000383","article-title":"Successful discharge to community from home health less likely for people in late stages of dementia","volume":"47","author":"Knox","year":"2024","journal-title":"J. Geriatr. Phys. Ther."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"e70013","DOI":"10.1002\/gps.70013","article-title":"Family care partner\u2019s preparedness in caring for hospitalized persons with dementia","volume":"39","author":"Paudel","year":"2024","journal-title":"Int. J. Geriatr. Psychiatry"},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"435","DOI":"10.1016\/j.jpainsymman.2024.07.026","article-title":"Transitional care of people with dementia and caregivers in the ADRD-PC trial: A mixed methods study","volume":"68","author":"Toles","year":"2024","journal-title":"J. Pain Symptom Manag."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"34","DOI":"10.3928\/00989134-20240312-03","article-title":"Health trajectories of skilled nursing facility patients with dementia: Evidence for practicing nurses","volume":"50","author":"Toles","year":"2024","journal-title":"J. Gerontol. Nurs."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"105057","DOI":"10.1016\/j.jamda.2024.105057","article-title":"Home health quality among hospitalized older adults with Alzheimer\u2019s disease and related dementia: Association with race\/ethnicity and dual eligibility before and during the COVID pandemic","volume":"25","author":"Yang","year":"2024","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"66S","DOI":"10.1177\/08982643241309443","article-title":"Resigned but resilient: Caregiver perceptions of role ambiguity and quality of care during hospital-to-home transitions of older Latinos living with dementia","volume":"37","author":"Greyson","year":"2025","journal-title":"J. Aging Health"},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1016\/j.gerinurse.2025.01.012","article-title":"Feasibility and acceptability of post-hospitalization discharge calls to caregivers of Veterans with dementia: A quality improvement project","volume":"62","author":"Idso","year":"2025","journal-title":"Geriatr. Nurs."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"144","DOI":"10.1177\/1545968311416990","article-title":"Effectiveness of intensive inpatient rehabilitation treatment on disease progression in parkinsonian patients: A randomized controlled trial with 1-year follow-up","volume":"26","author":"Frazzitta","year":"2012","journal-title":"Neurorehabilit. Neural Repair"},{"key":"ref_69","first-page":"583278","article-title":"Short- and long-term efficacy of intensive rehabilitation treatment on balance and gait in parkinsonian patients: A preliminary study with a 1-year followup","volume":"2013","author":"Frazzitta","year":"2013","journal-title":"Park. Dis."},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"340","DOI":"10.1177\/1352458517735188","article-title":"Longer term effectiveness of inpatient multidisciplinary rehabilitation on health-related quality of life in MS patients: A pragmatic randomized controlled trial\u2014The Danish MS Hospitals Rehabilitation Study","volume":"24","author":"Boesen","year":"2018","journal-title":"Mult. Scler."},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"828","DOI":"10.1136\/jnnp-2017-316437","article-title":"Efficacy of intensive multidisciplinary rehabilitation in Parkinson\u2019s disease: A randomised controlled study","volume":"89","author":"Ferrazzoli","year":"2018","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_72","doi-asserted-by":"crossref","unstructured":"Isernia, S., Di Tella, S., Pagliari, C., Jonsdottir, J., Castiglioni, C., Gindri, P., Salza, M., Gramigna, C., Palumbo, G., and Molteni, F. (2020). Effects of an innovative telerehabilitation intervention for people with Parkinson\u2019s disease on quality of life, motor, and non-motor abilities. Front. Neurol., 11.","DOI":"10.3389\/fneur.2020.00846"},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"1953","DOI":"10.1177\/1352458519884244","article-title":"Can inpatient multidisciplinary rehabilitation improve health-related quality of life in MS patients on the long term\u2014The Danish MS Hospitals Rehabilitation Study","volume":"26","author":"Boesen","year":"2020","journal-title":"Mult. Scler."},{"key":"ref_74","first-page":"4315489","article-title":"Self-reported nonadherence predicts changes of medication after discharge from hospital in people with Parkinson\u2019s disease","volume":"2020","author":"Feldmann","year":"2020","journal-title":"Park. Dis."},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"1336","DOI":"10.4103\/1673-5374.301029","article-title":"Efficacy of short-term multidisciplinary intensive rehabilitation in patients with different Parkinson\u2019s disease motor subtypes: A prospective pilot study with 3-month follow-up","volume":"16","author":"Chen","year":"2021","journal-title":"Neural Regen. Res."},{"key":"ref_76","doi-asserted-by":"crossref","unstructured":"Kuendig, S., Kool, J., Polhemus, A., Schallert, W., Bansi, J., and Gonzenbach, R.R. (2022). Three weeks of rehabilitation improves walking capacity but not daily physical activity in patients with multiple sclerosis with moderate to severe walking disability. PLoS ONE, 17.","DOI":"10.1371\/journal.pone.0274348"},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"104929","DOI":"10.1016\/j.msard.2023.104929","article-title":"Effects of inpatient energy management education and high-intensity interval training on health-related quality of life in persons with multiple sclerosis: A randomized controlled superiority trial with six-month follow-up","volume":"78","author":"Patt","year":"2023","journal-title":"Mult. Scler. Relat. Disord."},{"key":"ref_78","doi-asserted-by":"crossref","unstructured":"Steendam-Oldekamp, E., Weerkamp, N., Vonk, J.M., Bloem, B.R., and van Laar, T. (2023). Combined multidisciplinary in\/outpatient rehabilitation delays definite nursing home admission in advanced Parkinson\u2019s disease patients. Front. Neurol., 14.","DOI":"10.3389\/fneur.2023.1128891"},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"224","DOI":"10.7224\/1537-2073.2022-071","article-title":"Shedding light on the black box of rehabilitation: Differential short- and long-term effects of multidisciplinary multiple sclerosis rehabilitation","volume":"26","author":"Boesen","year":"2024","journal-title":"Int. J. MS Care"},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"107834","DOI":"10.1016\/j.parkreldis.2025.107834","article-title":"Impact of inpatient mobility on outcomes in Parkinson\u2019s disease","volume":"135","author":"Gunzler","year":"2025","journal-title":"Park. Relat. Disord."},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1186\/s12966-026-01888-y","article-title":"Post-rehabilitation self-management support on physical activity and nutrition, including mHealth, improves physical capacity, physical activity, and health related quality of life in people with Parkinson\u2019s: Results from a randomised controlled trial","volume":"23","author":"Alnes","year":"2026","journal-title":"Int. J. Behav. Nutr. Phys. Act."},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1007\/s00415-026-13697-1","article-title":"Comprehensive effects of Parkinson\u2019s disease multimodal complex treatment (PD-MCT): A two-center prospective trial","volume":"273","author":"Friedrich","year":"2026","journal-title":"J. Neurol."},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"1238","DOI":"10.1136\/jnnp.2010.206680","article-title":"Home telemonitoring of non-invasive ventilation decreases healthcare utilisation in a prospective controlled trial of patients with amyotrophic lateral sclerosis","volume":"81","author":"Pinto","year":"2010","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"883","DOI":"10.1089\/tmj.2010.0042","article-title":"Implementation of a wireless device for real-time telemedical assistance of home-ventilated amyotrophic lateral sclerosis patients: A feasibility study","volume":"16","author":"Pinto","year":"2010","journal-title":"Telemed. J. E Health"},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1258\/jtt.2009.090604","article-title":"A pilot trial of telemedicine-assisted, integrated care for patients with advanced amyotrophic lateral sclerosis and their caregivers","volume":"16","author":"Vitacca","year":"2010","journal-title":"J. Telemed. Telecare"},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"494","DOI":"10.3109\/17483107.2011.652999","article-title":"Tele-assistance in patients with amyotrophic lateral sclerosis: Long term activity and costs","volume":"7","author":"Vitacca","year":"2012","journal-title":"Disabil. Rehabil. Assist Technol."},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1212\/01.wnl.0000438227.48470.62","article-title":"Cluster RCT of case management on patients\u2019 quality of life and caregiver strain in ALS","volume":"82","author":"Creemers","year":"2014","journal-title":"Neurology"},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"180","DOI":"10.3109\/21678421.2014.971811","article-title":"Need and value of case management in multidisciplinary ALS care: A qualitative study on the perspectives of patients, spousal caregivers and professionals","volume":"16","author":"Bakker","year":"2015","journal-title":"Amyotroph. Lateral Scler. Front. Degener."},{"key":"ref_89","doi-asserted-by":"crossref","unstructured":"Cordesse, V., Sidorok, F., Schimmel, P., Holstein, J., and Meininger, V. (2015). Coordinated care affects hospitalization and prognosis in amyotrophic lateral sclerosis: A cohort study. BMC Health Serv. Res., 15.","DOI":"10.1186\/s12913-015-0810-7"},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"e028525","DOI":"10.1136\/bmjopen-2018-028525","article-title":"Using telehealth in motor neuron disease to increase access to specialist multidisciplinary care: A UK-based pilot and feasibility study","volume":"9","author":"Hobson","year":"2019","journal-title":"BMJ Open"},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1002\/mus.26170","article-title":"Multidisciplinary amyotrophic lateral sclerosis telemedicine care: The store and forward method","volume":"59","author":"Pulley","year":"2019","journal-title":"Muscle Nerve"},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1080\/21678421.2020.1718712","article-title":"Telehealth as part of specialized ALS care: Feasibility and user experiences with ALS home-monitoring and coaching","volume":"21","author":"Helleman","year":"2020","journal-title":"Amyotroph. Lateral Scler. Front. Degener."},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1080\/21678421.2020.1773502","article-title":"Telemedicine is a useful tool to deliver care to patients with amyotrophic lateral sclerosis during COVID-19 pandemic: Results from Southern Italy","volume":"21","author":"Capozzo","year":"2020","journal-title":"Amyotroph. Lateral Scler. Front. Degener."},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1017\/cjn.2020.240","article-title":"Transitions in Amyotrophic Lateral Sclerosis: Patient and Caregiver Experiences","volume":"48","author":"Munan","year":"2021","journal-title":"Can. J. Neurol. Sci."},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1111\/ane.13373","article-title":"Telehealth approach for amyotrophic lateral sclerosis patients: The experience during COVID-19 pandemic","volume":"143","author":"Sarnelli","year":"2021","journal-title":"Acta Neurol. Scand."},{"key":"ref_96","doi-asserted-by":"crossref","unstructured":"Dontje, M.L., Kruitwagen-van Reenen, E., van Wijk, E., Baars, E., Visser-Meily, J.M.A., and Beelen, A. (2022). Evaluation of the nation-wide implementation of ALS home monitoring & coaching: An e-health innovation for personalized care for patients with motor neuron disease. BMC Health Serv. Res., 22.","DOI":"10.1186\/s12913-022-08724-6"},{"key":"ref_97","first-page":"00438","article-title":"At-home noninvasive ventilation initiation with telemonitoring in amyotrophic lateral sclerosis patients: A retrospective study","volume":"9","author":"Bouteleux","year":"2023","journal-title":"ERJ Open Res."},{"key":"ref_98","doi-asserted-by":"crossref","first-page":"469","DOI":"10.1055\/s-0043-1768161","article-title":"Telehealth for amyotrophic lateral sclerosis in a multidisciplinary service in a Brazilian reference center","volume":"81","author":"Fidelix","year":"2023","journal-title":"Arq. Neuropsiquiatr."},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"937","DOI":"10.1002\/mus.28218","article-title":"Homecare amyotrophic lateral sclerosis (ALS): A multidisciplinary, home-based model of care for patients with ALS and their caregivers","volume":"70","author":"Bublitz","year":"2024","journal-title":"Muscle Nerve"},{"key":"ref_100","doi-asserted-by":"crossref","first-page":"366","DOI":"10.3349\/ymj.2024.0145","article-title":"Telemedicine experiences of people living with amyotrophic lateral sclerosis at home in South Korea","volume":"66","author":"Kim","year":"2025","journal-title":"Yonsei Med. J."},{"key":"ref_101","doi-asserted-by":"crossref","first-page":"483","DOI":"10.1177\/10499091241266985","article-title":"Characteristics of patients with amyotrophic lateral sclerosis followed by a home palliative care team","volume":"42","author":"Mercadante","year":"2025","journal-title":"Am. J. Hosp. Palliat. Care"},{"key":"ref_102","doi-asserted-by":"crossref","unstructured":"Schmidt, R., Slotina, E., Meissner, F., Metelmann, M., Ilse, B., Vogt, V., and Freytag, A. (2025). Palliative care pathways in amyotrophic lateral sclerosis (ALS): A sequence analysis of health claims data. BMC Palliat. Care, 24.","DOI":"10.1186\/s12904-025-01843-x"},{"key":"ref_103","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1177\/10499091241312906","article-title":"Living will and advance care planning in patients with amyotrophic lateral sclerosis admitted to specialistic home palliative care","volume":"43","author":"Mercadante","year":"2026","journal-title":"Am. J. Hosp. Palliat. Care"},{"key":"ref_104","doi-asserted-by":"crossref","first-page":"560","DOI":"10.1016\/j.jpainsymman.2025.12.026","article-title":"Clinical changes in patients with amyotrophic lateral sclerosis admitted to a home care program","volume":"71","author":"Mercadante","year":"2026","journal-title":"J. Pain Symptom Manag."},{"key":"ref_105","doi-asserted-by":"crossref","unstructured":"Ashbourne, J., Boscart, V., Meyer, S., Tong, C.E., and Stolee, P. (2021). Health care transitions for persons living with dementia and their caregivers. BMC Geriatr., 21.","DOI":"10.1186\/s12877-021-02235-5"},{"key":"ref_106","doi-asserted-by":"crossref","first-page":"1189","DOI":"10.1007\/s11606-020-06332-w","article-title":"Complex Transitions from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives","volume":"36","author":"Carnahan","year":"2021","journal-title":"J. Gen. Intern. Med."},{"key":"ref_107","doi-asserted-by":"crossref","first-page":"2899","DOI":"10.1111\/jgs.17321","article-title":"Outcomes of post-acute care in skilled nursing facilities in Medicare beneficiaries with and without a diagnosis of dementia","volume":"69","author":"Burke","year":"2021","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_108","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1016\/j.jagp.2021.06.013","article-title":"Skilled Nursing Facility-to-Home Trajectories for Older Adults with Mental Illness or Dementia","volume":"30","author":"Simning","year":"2022","journal-title":"Am. J. Geriatr. Psychiatry"},{"key":"ref_109","doi-asserted-by":"crossref","first-page":"e2015470","DOI":"10.1001\/jamanetworkopen.2020.15470","article-title":"Assessment of Receipt of the First Home Health Care Visit After Hospital Discharge Among Older Adults","volume":"3","author":"Li","year":"2020","journal-title":"JAMA Netw. Open"},{"key":"ref_110","doi-asserted-by":"crossref","first-page":"2496","DOI":"10.1016\/j.jamda.2021.09.001","article-title":"Trends in Post-Acute Care Utilization During the COVID-19 Pandemic","volume":"22","author":"Werner","year":"2021","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_111","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1377\/hlthaff.2021.01408","article-title":"Out of Reach: Inequities in the Use of High-Quality Home Health Agencies","volume":"41","author":"Rahman","year":"2022","journal-title":"Health Aff."},{"key":"ref_112","doi-asserted-by":"crossref","first-page":"747","DOI":"10.1177\/1077558720952298","article-title":"Early Effects of Home Health Value-Based Purchasing on Quality Star Ratings","volume":"78","author":"Teshale","year":"2021","journal-title":"Med. Care Res. Rev."},{"key":"ref_113","doi-asserted-by":"crossref","first-page":"1090","DOI":"10.1002\/mdc3.13789","article-title":"Antiparkinsonian Medication Reconciliation as a Strategy to Improve Safety by Preventing Medication Errors","volume":"10","author":"Riera","year":"2023","journal-title":"Mov. Disord. Clin. Pract."},{"key":"ref_114","doi-asserted-by":"crossref","unstructured":"Yu, J.R.T., Sokola, B.S., and Walter, B.L. (2023). Optimization of inpatient medication administration among persons with Parkinson\u2019s disease: Recommendations on pharmacy technology and workflow. Front. Pharmacol., 14.","DOI":"10.3389\/fphar.2023.1254757"},{"key":"ref_115","doi-asserted-by":"crossref","first-page":"989","DOI":"10.1177\/1352458521999970","article-title":"Prioritizing progressive MS rehabilitation research: A call from the International Progressive MS Alliance","volume":"27","author":"Zackowski","year":"2021","journal-title":"Mult. Scler."},{"key":"ref_116","doi-asserted-by":"crossref","first-page":"1459","DOI":"10.1177\/1352458520915629","article-title":"Exercise and lifestyle physical activity recommendations for people with multiple sclerosis throughout the disease course","volume":"26","author":"Kalb","year":"2020","journal-title":"Mult. Scler."},{"key":"ref_117","doi-asserted-by":"crossref","first-page":"jrm40641","DOI":"10.2340\/jrm.v56.40641","article-title":"Exercise-based telerehabilitation for patients with multiple sclerosis using physical activity: A systematic review","volume":"56","author":"Sladeckova","year":"2024","journal-title":"J. Rehabil. Med."},{"key":"ref_118","doi-asserted-by":"crossref","first-page":"106225","DOI":"10.1016\/j.msard.2024.106225","article-title":"Tele-exercise in multiple sclerosis: Systematic review and meta-analysis of effects on fatigue, depression, and overall health","volume":"93","author":"Najafi","year":"2025","journal-title":"Mult. Scler. Relat. Disord."},{"key":"ref_119","doi-asserted-by":"crossref","first-page":"E1453","DOI":"10.1503\/cmaj.191721","article-title":"Canadian best practice recommendations for the management of amyotrophic lateral sclerosis","volume":"192","author":"Shoesmith","year":"2020","journal-title":"CMAJ."},{"key":"ref_120","doi-asserted-by":"crossref","first-page":"e16264","DOI":"10.1111\/ene.16264","article-title":"European Academy of Neurology (EAN) guideline on the management of amyotrophic lateral sclerosis in collaboration with European Reference Network for Neuromuscular Diseases (ERN EURO-NMD)","volume":"31","author":"Andersen","year":"2024","journal-title":"Eur. J. Neurol."},{"key":"ref_121","doi-asserted-by":"crossref","first-page":"1918","DOI":"10.1111\/ene.14393","article-title":"Amyotrophic lateral sclerosis: A clinical review","volume":"27","author":"Masrori","year":"2020","journal-title":"Eur. J. Neurol."},{"key":"ref_122","doi-asserted-by":"crossref","first-page":"220269","DOI":"10.1183\/20734735.0269-2022","article-title":"The complexity of multidisciplinary respiratory care in amyotrophic lateral sclerosis","volume":"19","author":"Berlowitz","year":"2023","journal-title":"Breathe"},{"key":"ref_123","doi-asserted-by":"crossref","first-page":"911","DOI":"10.1007\/s10072-020-05011-2","article-title":"Multidisciplinary care in Amyotrophic Lateral Sclerosis: A systematic review and meta-analysis","volume":"42","year":"2021","journal-title":"Neurol. Sci."},{"key":"ref_124","doi-asserted-by":"crossref","first-page":"n2061","DOI":"10.1136\/bmj.n2061","article-title":"A new framework for developing and evaluating complex interventions: Update of Medical Research Council guidance","volume":"374","author":"Skivington","year":"2021","journal-title":"BMJ"}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/4\/445\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T04:23:20Z","timestamp":1785385400000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/4\/445"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,28]]},"references-count":124,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["medsci14040445"],"URL":"https:\/\/doi.org\/10.3390\/medsci14040445","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,28]]}}}