Key result
Nurse-led transitional care achieves high patient satisfaction but faces significant communication challenges with office-based physicians.
Why the study?
Older patients with cardiovascular disease discharged from the hospital are at increased risk of 30-day readmission, prompting evaluation of an innovative post-discharge navigation and care-coordination program.
Does a nurse-led transitional care model improve patient satisfaction and care coordination in patients with cardiovascular diseases discharged from the hospital?
RCT (n=2,550)
1:1
Yes
Does a nurse-led transitional care model improve patient satisfaction and care coordination in patients with cardiovascular diseases discharged from the hospital?
A nurse-led transitional care program for cardiovascular patients achieved high patient satisfaction with the nurses but failed to improve overall care satisfaction compared to standard care, highlighting the challenge of integrating hospital-initiated care models with ambulatory physicians.
Answers are grounded in this paper and cite their sources.
High satisfaction with study nurses failed to improve overall scores versus control; challenges cross-sectoral reach and extends evidence on transitional care barriers in cardiovascular disease.
Background Patients with higher age suffering from cardiovascular disease discharged from hospital are at greater risk of readmission within 30 days. We evaluated an innovative care program providing post-discharge support and helping patients to navigate through the healthcare system. This paper reports the findings of the process evaluation of the randomized controlled trial Cardiolotse, a nurse-led transitional care model improving care coordination for patients with cardiovascular diseases in Germany. Methods A process evaluation, following the guidelines of the Medical Research Council (MRC) Framework, was performed. Semi-structured interviews with all relevant target groups were conducted to gain more insight about implementation processes. Questionnaires and medical records were used to explore mechanisms of impact and understand how change was produced in the intervention. Qualitative data were analysed using content analysis with deductive and inductive categories. Descriptive statistics and subgroup analyses were utilized to explore quantitative data. Results Overall, the designed training programme was perceived positively by the study nurses, so called Cardiolotsen (CLs). Patients receiving support by the CLs reported positive satisfaction ratings. Interactions between CLs and patients were reported as trustworthy and reliable. A total of approximately 12,500 contacts were made over the course of the intervention. However, changes in satisfaction scores between intervention and control groups in terms of medical treatment or the interaction between medical health providers involved in the treatment could not be determined. Furthermore, data suggested reach issues with respect to office-based physicians, as regular CL contact could not be achieved with 90% of the participating general practitioners and cardiologists. Conclusions The CLs served as an important source of support for the participating patients throughout the intervention. At regular intervals, they checked a patient’s health status and their adherence to therapies after discharge. However, the process evaluation identified cross-sectoral communication and information exchange between CLs and office-based physicians as an implementation challenge. Trial registration The study was retrospectively registered at German Clinical Trial Register, http://www.drks.de/DRKS00020424 (Trial Registration Number DRKS00020424) on 18 June 2020.
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Kropp et al. (2026) conducted an RCT in Cardiovascular diseases (coronary artery disease, cardiac arrhythmias, heart failure) (n=2,550). Nurse-led transitional care model (Cardiolotse) vs. Treatment as usual (TAU) was evaluated on Patient satisfaction and implementation process metrics (process evaluation). The nurse-led transitional care model (Cardiolotse) achieved high patient satisfaction and regular follow-up contacts, but faced significant implementation challenges regarding cross-sectoral communication with office-based physicians.
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