Transitions of care between acute hospital and community settings are points of vulnerability for people with geriatric syndrome. Routinely including informal caregivers into the transition processes may mitigate risk. Guidance for operational aspects of caregiver inclusion is currently lacking in healthcare policy and fails to address the barriers faced by caregivers and healthcare professionals.

This pilot mixed method study adopts an implementation science lens to “bridge the gap” between top-down policy recommendations and the realities experienced by healthcare professionals who provide transitional care. It explores how informal caregiver integration can be better achieved. In the past, caregiver integration literature has focused the role of nurses and case managers in this role. However, in true person-centred integrated care, discharge planning and caregiver inclusion is the responsibility of every healthcare professional. This study conducted a pilot to explore these concepts and challenges in physiotherapists at a private hospital in New South Wales, Australia. Physiotherapists were selected because they are highly likely to encounter geriatric syndrome due to the patients’ functional decline. Also, within the multidisciplinary team, their skills are essential to discharge planning and their role encompasses community social support and emphasises person centred care, and so they are also likely to interact with caregivers.