Nurse-Led Discharge Program and Primary Care Outcomes: A Proof-of-concept Cluster Randomized Controlled Trial

March 4, 2026 updated by: The University of Hong Kong

Effectiveness of the Nurse-led Discharge Interventions in Promoting Hospital Patients' Primary Health Care Outcomes on Discharge: A Proof-of-concept Cluster Randomized Controlled Trial

The goal of this cluster randomized controlled trial is to evaluate whether a nurse-led primary health care (PHC) discharge intervention can improve patient activation and primary health care-related outcomes among hospitalized adult patients after discharge.

Study Overview

Status

Not yet recruiting

Conditions

Intervention / Treatment

Detailed Description

Chronic diseases account for approximately 74% of global deaths and remain the leading cause of morbidity and mortality worldwide and in Hong Kong, particularly ischemic heart disease, cerebrovascular disease, and diabetes-related complications. The growing burden of ageing populations and non-communicable diseases highlights the need to shift healthcare systems from secondary and tertiary care toward prevention-oriented primary health care (PHC).

PHC serves as the first point of contact in a continuous healthcare process and is essential to a sustainable healthcare system. In response, Hong Kong is implementing a PHC reform through the establishment of District Health Centres to enhance population health and reduce pressure on public hospitals. Nurses, as the largest healthcare workforce, play a critical role in PHC delivery; however, nursing training in Hong Kong remains predominantly hospital-focused. Strengthening hospital nurses' roles in PHC-oriented discharge education may improve care continuity, patient self-management, and long-term health outcomes while reducing hospital readmissions and healthcare costs.

The aims of study are as follows:

  1. To determine the main effect of the Intervention vs. Control group on Patient Activation Measure at 3-month follow-up after discharge (Primary)
  2. To assess the effects on secondary outcomes at 3-month and 6-month follow-ups
  3. To identify mediators between intervention and outcomes to inform the potential mechanisms
  4. To qualitatively explore subjects' perceptions of managing their own health conditions after leaving the hospital and their experience of following the primary healthcare discharge intervention suggested by nurses.

Study Type

Interventional

Enrollment (Estimated)

120

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

  • Name: Siu Long Chau, PhD
  • Phone Number: +852 6700 9987
  • Email: cslmatt@hku.hk

Study Locations

  • Hong Kong
    • Hong Kong
      • Hong Kong, Hong Kong, Hong Kong, 000000
        • 18/F, Metro South Tower 1, 39 Wong Chuk Hang Road, Wong Chuk Hang, Hong Kong
        • Contact:
          • Siu Long Chau, PhD
          • Phone Number: +852 6700 9987
          • Email: cslmatt@hku.hk
        • Principal Investigator:
          • Siu Long Chau, PhD

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Child
  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Hong Kong residents aged ≥18 years
  • Able to read and communicate in Chinese (Cantonese or Mandarin)
  • Being hospitalized for more than 24 hours
  • Stable medical condition upon hospital discharge

Exclusion Criteria:

  • Having a history of psychiatric/psychological disease or currently on regular psychotropic medications
  • Currently participating in other primary healthcare programmes

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Intervention group
  1. primary healthcare discharge education
  2. specially-designed health education leaflet
  3. patient discharge package
Behavioral: Primary healthcare discharge education
The primary healthcare discharge education begins by identifying priorities to address related to patients' life situations (using the Instrument for Patient Capacity Assessment) and determining the patient's current level of activation (using the Patient Activation Measure). A discharge education guide developed by the research team helps to individualize the teaching according to the patient's priorities and activation level.
Behavioral: specially-designed health education leaflet
  1. Introduction of the District Health Centres/Expresses;
  2. Life Course Preventive Care Plan pamphlet;
  3. Provide disease-specific discharge/rehabilitation advice and relevant health education materials with an emphasis on prevention and self-care management;
  4. The hospital nurses will help discharge patients download and install the "HA Go" mobile app.
Behavioral: Patient discharge package

Subjects in the intervention group will receive the following items with instructions for use upon hospital discharge:

  1. Blood pressure monitor
  2. Blood glucose test strip
  3. Soft ruler to measure weight circumference
  4. Resistance bands for simple exercise
Active Comparator: Control Group
usual hospital discharge practice
Behavioral: usual hospital discharge practice
The control group will receive the usual hospital discharge practice upon discharge.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
The primary outcome is the change in the Patient Activation Measure (PAM) between baseline and 3-month follow-up.
Time Frame: From baseline to 3-month follow up.
The PAM is a 13-item self-report questionnaire to measure patient activation level [18]. Patients can go through four levels of activation: (1) disengaged and overwhelmed, (2) becoming aware but still struggling, (3) taking action, and (4) maintaining behaviors and pushing further [18].PAM raw score can be calculated by adding all of the responses to the 13 questions [18]. This score is then converted into an activation score ranging from 0 = no activation to 100 = high activation using a scoresheet provided by Insignia Health.
From baseline to 3-month follow up.

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

The University of Hong Kong

Collaborators

Queen Mary Hospital, Hong Kong

Investigators

  • Principal Investigator: Siu Long Chau, PhD, HKU

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Estimated)

March 1, 2026

Primary Completion (Estimated)

February 1, 2027

Study Completion (Estimated)

June 1, 2027

Study Registration Dates

First Submitted

March 4, 2026

First Submitted That Met QC Criteria

March 4, 2026

First Posted (Actual)

March 9, 2026

Study Record Updates

Last Update Posted (Actual)

March 9, 2026

Last Update Submitted That Met QC Criteria

March 4, 2026

Last Verified

January 1, 2026

More Information

Terms related to this study

Keywords

Other Study ID Numbers

  • currently not available

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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