Provencher V, Clemson L, Wales K, et al. - Whether an evidence-based discharge planning intervention would have a more beneficial impact on the outcomes such as independence in activities of daily living (ADL), participation in life roles, unplanned re-hospitalizations, and emergency department (ED) presentations, among subgroups of older patients at risk of experiencing difficulty executing ADL after hospital discharge, as well as unplanned hospital readmissions and ED presentations, compared with their counterparts, was investigated. Data were obtained from a randomized control trial including 400 hospitalized older patients with acute and medical conditions, selected through 5 sites in Australia. The participants were assigned to receive either a patient-centered discharge planning intervention (named as HOME) led by an occupational therapist; or a structured in-hospital consultation. HOME involved a collaborative approach for goal setting as well as pre and post-discharge home visits and telephone follow-up. For hospitalized older adults with mild cognitive impairment, a reduction in unplanned re-hospitalizations was brought about by the HOME intervention, which included preparation and postdischarge support in the environment. Best care delivery during the transition from hospital to home may be enabled by improved discharge outcomes noted in this at-risk subgroup after an occupational therapist-led intervention.