The ageing of the Australian population presents a significant challenge to the delivery of health services . A significant proportion (13%) of people in Australia is now aged over 65 years , with almost one quarter of these older persons suffering from a severe or profound disability . Maintaining functional ability and independence is thus becoming increasingly important to sustain or improve older people's quality of life and contain health care costs. Older people are found to have higher rates of hospital admission and length of stay than the general population. In 2008-09, approximately 3 million separations were recorded by public and private hospitals throughout Australia for older admitted patients (65 years and older), representing 37% of all separations . These rates are comparable to other developed countries where persons aged 65 years and older account for approximately 38%  and 36%  of hospital admissions in the United Kingdom and United States, respectively.
During hospitalisation older people experience significant functional decline which results in loss of independence, decreased quality of life, and an increased rate of readmission [7–9]. Functional ability is closely tied to quality of life as it is essential for independence in the performance of activities of daily living (ADLs) (e.g., bathing, dressing, transferring, toileting, continence, and feeding) and instrumental activities of daily living (IADLs) (e.g., travelling, shopping, preparing meals, housework, and managing medications, the telephone, and money). One study found that of 1279 community-dwelling patients aged 70 years or over who were admitted to hospital for an acute medical illness, 32% were found to have a decreased ability to perform ADL functions on discharge compared with their pre-admission baseline, with the largest decline occurring in bathing and dressing . At 3 months after discharge, 40% of the study population were found to have a new ADL and/or IADL disability, indicating that functional decline can be long-term. German et al.  therefore argue that quality of life can be increased if the rate of hospitalisations for acute episodes can be reduced or eliminated.
The successful move away from institutional-based care has resulted in higher numbers of older adults living at home, often cared for by relatives or spouses of a similar age . Transitional care between hospital and home is required which effectively enables both the older person and their carer, if applicable, to manage at home. Discharge planning aims to improve patient outcomes and contain costs through an in-depth assessment and the development of an individualised plan for the patient prior to leaving hospital. Inadequate assessment of mental and physical status, social and health service support may result in a failure to recognise potential problems which contribute to readmissions. In a systematic review, Shepperd et al.  found evidence that discharge planning reduces readmission to hospital and hospital length of stay for older adults with a medical condition. A variety of strategies have been used to strengthen discharge planning, such as early screening, specialised geriatric programs, liaison nurses, and case management . However, strategies are rarely evaluated directly, as outcomes are often assessed by systems measures such as length of hospital stay, rate of readmission and/or costs, rather than focusing on functional ability or psycho-social well-being and of the older person .
Evaluations have found readmissions to acute care facilities are decreased with in-home follow-up by nurses [13, 14] and that exercise programs, in particular home-based programs, have shown promising results on the health outcomes of older adults .
Evidence surrounding case management models for older people, however, remains controversial [16, 17]. Lowe and Kasap  describe a new model for reorganisation of geriatric and general medical services in a tertiary referral hospital. An iterative process of bed utilisation review, stakeholder consultation, and service remodelling was undertaken to improve bed management and resulted in a reduced length of stay, increased throughput and recurrent cost savings. However, limited work has been undertaken on the promotion of health behaviour change to improve the functional ability of older people at high risk of poor outcomes following discharge in order to improve the maintenance of independence and quality of life.
This research team previously completed a randomised controlled trial investigating the effectiveness of an innovative model of discharge planning and follow-up management of older adults at risk for hospital readmission . The current trial extends this work to determine the effectiveness, as compared to that of receiving usual care, of interventions that 1) combine in-home and telephone follow-up management with hospital-to-home exercise strategies as outlined in the previous trial , 2) exercise strategies only intervention, and 3) an in-home and telephone follow-up only intervention. At the writing of this article (December 2010 to March 2011), ethics approval has been obtained and the interventions and data collection from the participants is underway.
The overall aim of this trial is to evaluate the relative effectiveness of transitional care strategies commencing during hospitalisation for community-based high risk older adults on emergency readmissions and health service use, functional ability and quality of life outcomes. Specifically, the aims are to:
1. Conduct a randomised control trial to compare and evaluate transitional care interventions targeting older patients aged over 65 years who are at risk of hospital readmission after discharge;
2. Compare and evaluate innovative exercise and telephone follow-up interventions following discharge in comparison to usual care, on primary and secondary outcomes at 4 weeks, 12 weeks, and 24 weeks. Primary outcomes include emergency health service use (i.e. unplanned readmissions, time to first unplanned readmission, unplanned Emergency Department, General Practitioner and other health service use), and functional ability. Secondary outcomes include health-related quality of life, psychosocial well-being, and cost effectiveness; and
3. Apply the RE-AIM evaluation framework  which uses Reach, Effectiveness, Adoption, Implementation, and Maintenance to assist in understanding the various factors which impact upon the intervention becoming a routine part of the usual care provided by a health service.