Hospital readmissions within 30 days continue to be a challenge for healthcare systems, particularly in the case of frail, elderly patients and those with chronic diseases. From international studies, it emerges that the transition phase between hospital and community is configured as a critical moment, often marked by interruptions in care continuity, lack of coordination, and overload for families [1]. The reduction of readmissions, as well as the continuity of care, has long been a shared goal, but despite the numerous articles in the literature, many questions remain open regarding the most effective ways to structure discharge and community care.
