Effectiveness of a Nurse-Led Transitional Care Model Based on the Fundamentals of Care Framework (NURSE-LEDFOC)
This study aims to find out whether nurse-led transitional care can help older adults with chronic health conditions recover safely after leaving the hospital. It also examines whether this approach can lower the risk of returning to the hospital within 30 days.
The study includes 652 adults aged 60 years or older with at least one long-term health condition. All participants were receiving care in medical wards at an Italian university hospital and were preparing to return home.
Participants were randomly assigned to one of two groups:
Nurse-led transitional care: Participants received additional care in a nurse-led unit before returning home. Nurses assessed their health and daily needs, provided personalized care and education, and helped plan a safe return home. This approach followed the Fundamentals of Care Framework, which focuses on meeting people's physical, emotional, and social care needs.
Usual care: Participants received standard hospital care and returned directly home after discharge, without the additional nurse-led transitional care program.
Researchers assessed participants' ability to perform daily activities, memory and thinking skills, risk of falls, and risk of developing pressure injuries (skin damage caused by prolonged pressure). They also checked whether participants returned to the hospital unexpectedly within 30 days.
By comparing the two groups, the study aims to understand whether additional nurse-led care can support recovery, improve independence, and help older adults remain safely at home after hospitalization.
Visão geral do estudo
Status
Intervenção / Tratamento
Tipo de estudo
Inscrição (Real)
Estágio
- Não aplicável
Contactos e Locais
Locais de estudo
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Rome, Itália, 00133
- Nursing Department
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Critérios de participação
Critérios de elegibilidade
Idades elegíveis para estudo
- Filho
- Adulto
- Adulto mais velho
Aceita Voluntários Saudáveis
Gêneros Elegíveis para o Estudo
Descrição
Inclusion Criteria:
- Adults aged 60 years or older.
- Diagnosis of at least one chronic condition (e.g., chronic obstructive pulmonary disease, diabetes, heart disease, heart failure, musculoskeletal disorders, or hypertension).
- Ability to understand the study information and provide informed consent.
- Planned discharge from an acute medical ward to their own home.
Exclusion Criteria:
- Participants requiring daily assistance from a family member or informal caregiver to perform activities of daily living.
- Inability to understand the study information or provide informed consent.
- Planned discharge to other healthcare or residential care settings, such as nursing homes or rehabilitation centers.
Plano de estudo
Como o estudo é projetado?
Detalhes do projeto
- Finalidade Principal: Pesquisa de serviços de saúde
- Alocação: Randomizado
- Modelo Intervencional: Atribuição Paralela
- Mascaramento: Solteiro
Armas e Intervenções
Grupo de Participantes / Braço |
Intervenção / Tratamento |
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Experimental: Community Hospital
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. |
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Comparador Ativo: Usual Care - Direct Discharge Home
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. |
O que o estudo está medindo?
Medidas de resultados primários
Medida de resultado |
Descrição da medida |
Prazo |
|---|---|---|
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Unplanned Hospital Readmission Within 30 Days
Prazo: Within 30 days after final hospital discharge
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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. |
Within 30 days after final hospital discharge
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Medidas de resultados secundários
Medida de resultado |
Descrição da medida |
Prazo |
|---|---|---|
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Change in Functional Independence Assessed by the Barthel Index
Prazo: Baseline and 30 days after final hospital discharge.
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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. |
Baseline and 30 days after final hospital discharge.
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Change in Pressure Injury Risk Assessed by the Braden Scale
Prazo: Baseline and 30 days after final hospital discharge.
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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. |
Baseline and 30 days after final hospital discharge.
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Change in Cognitive Status Assessed by the Short Portable Mental Status Questionnaire
Prazo: Baseline and 30 days after final hospital discharge.
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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. |
Baseline and 30 days after final hospital discharge.
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Change in Fall Risk Assessed by the Modified Morse Fall Scale
Prazo: Baseline and 30 days after final hospital discharge.
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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. |
Baseline and 30 days after final hospital discharge.
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Colaboradores e Investigadores
Patrocinador
Publicações e links úteis
Publicações Gerais
- Saari H, Lonnroos E, Kautiainen H, Kokko S, Ryynanen OP, Mantyselka P. Incidence of short-term community hospital stays and clinical profiles of patients: the Finnish Community Hospital Cohort Study. Scand J Prim Health Care. 2024 Mar;42(1):82-90. doi: 10.1080/02813432.2023.2291671. Epub 2024 Feb 7.
- Sun M, Qian Y, Liu L, Wang J, Zhuansun M, Xu T, Rosa RD. Transition of care from hospital to home for older people with chronic diseases: a qualitative study of older patients' and health care providers' perspectives. Front Public Health. 2023 Apr 27;11:1128885. doi: 10.3389/fpubh.2023.1128885. eCollection 2023.
- Recio-Saucedo A, Dall'Ora C, Maruotti A, Ball J, Briggs J, Meredith P, Redfern OC, Kovacs C, Prytherch D, Smith GB, Griffiths P. What impact does nursing care left undone have on patient outcomes? Review of the literature. J Clin Nurs. 2018 Jun;27(11-12):2248-2259. doi: 10.1111/jocn.14058. Epub 2017 Oct 16.
Datas de registro do estudo
Datas Principais do Estudo
Início do estudo (Real)
Conclusão Primária (Real)
Conclusão do estudo (Real)
Datas de inscrição no estudo
Enviado pela primeira vez
Enviado pela primeira vez que atendeu aos critérios de CQ
Primeira postagem (Real)
Atualizações de registro de estudo
Última Atualização Postada (Real)
Última atualização enviada que atendeu aos critérios de controle de qualidade
Última verificação
Mais Informações
Termos relacionados a este estudo
Termos MeSH relevantes adicionais
Outros números de identificação do estudo
- 669
- 2.26.3 (Número de outro subsídio/financiamento: Center of Excellence for Culture and Research Nursing of the Professions Order Nursing of Rome)
Plano para dados de participantes individuais (IPD)
Planeja compartilhar dados de participantes individuais (IPD)?
Descrição do plano IPD
De-identified individual participant data underlying the results reported in this study may be made available to qualified researchers upon reasonable request to the corresponding author. Data sharing will be subject to approval of the research team and compliance with applicable ethical and data protection requirements. No directly identifiable participant information will be shared.
Prazo de Compartilhamento de IPD
Beginning 6 months after publication of the study results and ending 5 years after publication
Critérios de acesso de compartilhamento IPD
De-identified individual participant data and supporting study documents may be made available to qualified researchers who submit a reasonable request to the corresponding author. Requests must include a research proposal describing the scientific objectives, planned analyses, and intended use of the data. Access will be subject to approval by the research team and compliance with applicable ethical and data protection requirements. Approved researchers will receive access to the data necessary for their proposed analyses through a secure data-sharing process. Data will not be made publicly available.
Tipo de informação de suporte de compartilhamento de IPD
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