Background:
Older adults are at higher risk of experiencing frequent healthcare transitions. We aimed to quantify and characterize the care transition patterns of older adults associated to individuals’ sociodemographic, clinical and functional characteristics.

Method:
Data are from the Swedish National Study on Aging and Care in Kungsholmen and the Swedish Patient Register through which we assessed care transitions between home, home care, nursing home and hospital in 3,363 older adults ≥60 years old. Markov multistate models were used to represent the study participants likelihood of moving across various care settings.

Results:
Over 15 years, the study participants spent on average after each transition two years at home, one year at home with home care, one year in a nursing home, eight days in hospital and 17 days in post-acute care. On average, study participants experienced ten hospitalizations over the study period. Being unpartnered was associated to a significant higher hazard of transitioning from home to hospital (HR 1.12) and to be discharged from hospital to home with home care (HR 1.18) or to a nursing home (***). Similarly, multimorbidity (2+ diseases) was associated with a higher hazard to transitioning from home to hospital (HR 1.56) and to be discharged at home with home care (HR 2.40). Cognitive impairment significantly increased the hazard to be institutionalized independently from the starting setting (HR range 2.14-3.48). Slow walking speed finally increased the hazard to be hospitalized (HR range 1.14-1.28) and to be discharged at home with home care services (HR 1.20).

Conclusion:
Different sociodemographic, clinical and functional characteristics trigger specific care transition patterns of older adults. Preventive strategies addressing individuals with such characteristics should be tested in the attempt to reduce healthcare fragmentation.