BACKGROUND: Inpatient hospitalisation is associated with adverse outcomes in older adults, including hospital-associated deconditioning. The hospital-at-home (HaH) model may promote physical activity. This systematic review and meta-analysis compares functional outcomes between inpatient and HaH settings and evaluates the efficacy of exercise interventions in both settings. METHODS: Systematic searches of PubMed, Scopus, Web of Science and ScienceDirect were conducted on 27 April 2024. Three distinct searches were performed: (i) studies comparing HaH and inpatient hospitalisation, (ii) trials evaluating inpatient exercise interventions and (iii) research on HaH exercise interventions. Two reviewers independently selected studies published from 2014 onwards using the PICOS framework and they assessed quality using PEDro scale. A meta-analysis was performed using a random effects model to analyse exercise interventions. This systematic review with meta-analysis was conducted according to PRISMA 2020 guidelines and was registered on PROSPERO (CRD42024598286). RESULTS: Among the 9470 studies identified, nine studies comparing acute-care settings and 21 studies on exercise interventions (one in HaH) were included. Findings suggest that HaH may positively affect functional and cognitive outcomes. Inpatient exercise interventions significantly improved physical performance [standardised mean difference (SMD) = 0.42, 95% confidence interval (CI) = 0.12-0.72] and functional independence (SMD = 0.45, 95% CI = 0.14-0.77) at discharge. CONCLUSION: HaH may contribute to preserving physical and cognitive status. Supervised exercise interventions during inpatient hospitalisation are safe and effective for improving older adults' functional status, although further research in the HaH model is needed.