Effectiveness of a Nurse-Led Transitional Care Model Based on the Fundamentals of Care Framework (NURSE-LEDFOC)

Participants assigned to this group received nurse-led transitional care in a Community Hospital before returning home. The intervention was based on the Fundamentals of Care Framework and included comprehensive nursing assessment, individualized care planning, daily clinical monitoring, patient education, and coordinated discharge planning. Nurses supported participants' physical, emotional, and social care needs, promoted self-care skills, and coordinated care with community health services. The maximum length of stay was 14 days, followed by a 30-day follow-up after discharge.

The intervention was based on the Fundamentals of Care Framework and included comprehensive nursing assessment, individualized care planning, daily clinical monitoring, patient education, and coordinated discharge planning. Nurses supported participants' physical, emotional, and social care needs, promoted self-care skills, and coordinated care with community health services. The maximum length of stay was 14 days, followed by a 30-day follow-up after discharge.

Participants assigned to this group received usual care in acute medical wards and were discharged directly home after clinical stabilization. They received standard discharge instructions and routine care, without transfer to a Community Hospital or participation in the structured nurse-led transitional care program. Community health services were provided when indicated according to usual clinical practice. Participants were followed up 30 days after discharge.

Participants received standard hospital care and returned directly home after discharge, without the additional nurse-led transitional care program.

The proportion of participants experiencing at least one unplanned hospital readmission within 30 days after final hospital discharge. Readmissions to any hospital in the Lazio region were identified using regional administrative hospital databases. The outcome was compared between the nurse-led transitional care group and the usual care group.

Functional independence was assessed using the Barthel Index, which measures the ability to perform 10 basic activities of daily living, including feeding, bathing, dressing, mobility, and personal hygiene. Total scores range from 0 to 100, with higher scores indicating greater independence. Changes from baseline were compared between the two study groups.

The risk of developing pressure injuries was assessed using the Braden Scale, which evaluates six areas: sensory perception, skin moisture, physical activity, mobility, nutrition, and friction or shear. Total scores range from 6 to 23, with lower scores indicating a higher risk of pressure injuries. Changes from baseline were compared between the two study groups.

Cognitive status was assessed using the Short Portable Mental Status Questionnaire (SPMSQ), a 10-item instrument evaluating orientation, memory, and basic cognitive functioning. According to the scoring system used in this study, total scores range from 0 to 11, with higher scores indicating better cognitive functioning. Changes from baseline were compared between the two study groups.

Fall risk was assessed using a modified version of the Morse Fall Scale consisting of six dichotomous items. Total scores range from 0 to 6, with higher scores indicating greater fall risk. Scores of 0-2 indicate low risk, 3-4 moderate risk, and 5-6 high risk. Changes from baseline were compared between the two study groups.