Effects of a transitional care model on hospital readmission, mortality, and health-related quality of life in older patients with chronic heart failure: a randomised controlled trial

Background and purpose: The hospital-to-home transition confers considerable burden to older patients with chronic heart failure (CHF). This study aimed to determine the impact of nurse-implemented transitional care (TC) on readmission and mortality among this cohort. Methods: 178 hospitalised older CHF patients with TC versus usual care were compared. The TC group received, in addition to usual care, a pre-discharge visit, 2 home visits, and regular telephone calls over 6 months to provide customised self-care empowerment, optimised health surveillance, prompt professional support, and facilitation in community services utilisation. Primary endpoints were event-free survival, all-cause hospital readmission, and mortality during the 9-month follow-up. Secondary endpoints were the length of hospital stay, self-care, and health-related quality of life (HRQOL). Data were analysed using survival analysis with Cox regression and general estimating equations. Results: The TC group had a shorter median length of hospital stay (7 [IQR, 5-8] days vs. 13 [IQR, 7-18] days, p=0.006) and improved self-care, and HRQOL. The TC group also had significantly fewer number of early readmission within 6 weeks of discharge. The reduced mortality risk in the TC group was almost significant (adjusted HR=0.45, 95% CI=0.19-1.05, p=0.066]. Conclusion: The nurse-implemented TC was an effective model of care to improve the post-discharge outcome of older CHF patients. Incorporating clinical care components such as protocol-guided drug titration may increase the survival benefits.