Why the study?
Effective coordination between hospital and primary care is essential to prevent readmissions in multimorbid patients, but local processes to assess and manage these readmission risks are lacking.
Does a nurse-led telehealth-based transitional care model reduce 3-month readmission rates in patients with multimorbidity after hospital discharge?
Population
Patients with multimorbidity discharged from 2 Australian teaching hospitals
Comparison
Nurse-led telehealth transitional care model vs standard care
Design
Multicenter pragmatic randomized controlled trial
Follow-up
Up to 12 months
Authors
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No practice change yet; this RCT will test whether nurse-led telehealth transitional care reduces readmissions in multimorbidity.
Does a nurse-led telehealth-based transitional care model reduce 3-month readmission rates in patients with multimorbidity after hospital discharge?
This protocol outlines a pragmatic randomized controlled trial to evaluate whether a nurse-led telehealth transitional care model can reduce readmissions in patients with multimorbidity.
Davis et al. (2025) studied this question.
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