BACKGROUND: Patients with osteoporotic fracture (OF) after discharge to home represent a vulnerable population who are susceptible to adverse events as a result of a poorly designed healthcare system in China. Transitional care (TC) has been proved to be effective in addressing fragmented care and preventing adverse outcomes, but the definitive description of TC that was used successfully in the real world for this group has not been formed in China. OBJECTIVE: The aim of this study was to evaluate the effect of a 24-week TC program on health outcomes in patients with OF. METHODS: It was a randomized controlled trial. Patients in the intervention group received ongoing rehabilitation both at the community healthcare centers and at home through a multidisciplinary team, while individuals in the control group received routine follow-up visits by primary healthcare physicians. Outcomes were measured by the Short-Form Health Survey-36 (SF-36), Modified Barthel Index (MBI), and Caregiver Strain Index (CSI) at 12 and 24 weeks, respectively. RESULTS: A total of 74 participants were randomly assigned (intervention n = 37, control n = 37). Mean values of the Physical Components Summary (PCS), an integral component of SF-36, and MBI were significantly better in the intervention group at 24 weeks (F 19.30, p = 0.000 and p = 21.24, p = 0.000, respectively). Mean values of the changes from the baseline to 24 weeks were significantly better in the intervention group regarding PCS (F 36.13, p = 0.000) and MBI (F 21.05, p = 0.000). CONCLUSION: The TC program has been proven to be feasible and to improve functional performance when applied to patients with OF. TRIAL REGISTRATION: China Clinical Trials on May 28, 2022, with registration number ChiCTR220006032.

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