Effect exerted by a hospital-home transition plan for people with Heart Failure: a randomized clinical trial

Q: What is the clinical evidence from this study?

Study design: RCT. Population: Heart Failure (n=100). Intervention: Plan Cuidarte (hospital-home transitional care nursing educational intervention) vs. Conventional discharge plan (usual care). Primary outcome: Overall care competence score (measured by the Cuidar instrument, range 0-60) (Hedges' g 0.93 (Cohen's d 0.94), 95% CI 0.52-1.35, p=0.000).

Q: What does this research mean for the field?

The hospital-to-home transition intervention Plan Cuidarte significantly improves care competence with a large effect size in patients with heart failure compared to conventional discharge planning. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Claudia Marcela Vallejo-Ramírez; John Edison Cárdenas Galvis; Gloria Carvajal Carrascal; Alejandra Fuentes-Ramírez; Beatriz Sánchez Herrera

doi:10.1590/1518-8345.8271.4942

January 1, 2026Revista Latino-Americana de EnfermagemOpen Access

Effect exerted by a hospital-home transition plan for people with Heart Failure: a randomized clinical trial

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Why the study?

The effect of the Plan Cuidarte intervention on care competence in people with heart failure during the hospital-home transition period needed to be determined.

Does the Plan Cuidarte hospital-home transition nursing intervention improve care competence compared to conventional discharge care in hospitalized adults with heart failure?

Study Design

Type

RCT (n=100)

Blinding

Single-blind (data analysts blinded; open-label for participants)

Randomization

1:1 permutation randomization via computer generator

Multicenter

Yes

Structured PICO

Does the Plan Cuidarte hospital-home transition nursing intervention improve care competence compared to conventional discharge care in hospitalized adults with heart failure?

P

Population

100 hospitalized older adults (mean age ~70 years, 38% female) with heart failure and preserved cognitive/functional autonomy across three Colombian hospitals, excluding transplant candidates and ICU patients, evaluated pre- and post-discharge intervention.

I

Intervention

Plan Cuidarte (Early and Structured Care Plan), an individualized, in-person nursing intervention based on Meleis' Theory of Transitions delivered during hospitalization alongside standard clinical care. Consists of two stages: Stage 1 (1 session, 30-40 minutes) assessing preparedness for the hospital-home transition using the GCPC-UN-D survey and baseline Cuidar instrument; Stage 2 (2 educational sessions: first session 20-30 minutes on Knowledge dimension, second session 30-40 minutes on Instrumental and Anticipation dimensions) utilizing a booklet, digital didactic module, and the Teach Back method covering HF definition, sign/symptom follow-up, pharmacological/non-pharmacological adherence, warning signs, and decision-making.

C

Comparator

Conventional discharge plan (usual discharge assistance) offered on the discharge date alongside standard clinical care, consisting of general care indications, explanation of discharge recommendations, administrative processes for requesting control appointments, procedures, and medications, plus a charge nurse explaining necessary care measures for prescribed medications.

O

Outcome

Care competence level (capacity, skill, and preparedness to perform care actions across six dimensions: Knowledge, Uniqueness, Instrumental, Enjoyment/well-being, Anticipation, and Social relations/interactions), measured pre- and post-intervention using the 20-item patient-reported Cuidar instrument (scored 0-60).patient reported

Main Result

Standardized Mean Difference: 0.93 (95% CI 0.52–1.35)

Absolute Event Rate: 40.84% vs 26.18%

p-value: p=0.000

Implementing the structured Plan Cuidarte educational nursing intervention during the hospital-to-home transition significantly improves self-care competence in hospitalized patients with heart failure compared to conventional discharge care.

Limitations

Care competence was assessed via self-reported measures.
Brief follow-up period precluded evaluation of long-term clinical and post-discharge outcomes such as readmissions, quality of life, or mortality.
Non-probability convenience sampling in a specific regional population limits generalizability.
Participants could not be blinded due to the educational nature of the intervention.
The ad hoc survey used to evaluate patient satisfaction lacked prior validation studies.
It was not possible to blind the participants due to the educational nature of the intervention
Non-probability convenience sampling was used prior to randomization
Follow-up loss rate of 17% (46 in Experimental Group and 37 in Comparison Group finished the study)
The satisfaction survey was developed ad hoc for the study and lacks validation studies

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

Supports incorporating structured transition education into heart failure discharge planning; extends randomized evidence for theory-based interventions.

Abstract

Objective: to determine the effect exerted by Plan Cuidarte on care competence in people with heart failure during the hospital-home transition period. Method: a randomized clinical trial of the pre- and post-test that included 100 participants (Experimental Group=50, Comparison Group=50). The Experimental Group was applied Plan Cuidarte, which includes two stages: the first one consists in assessing discharge training and the second one deals with discharge training by means of educational processes. The Comparison Group was offered the conventional discharge plan. An intention to treat analysis was performed with intra- and inter-group comparisons and the dependent variable was care competence, measured with the Cuidar instrument. The data were analyzed by means of descriptive and analytical statistics, following all research ethics principles. Results: the Experimental group participants presented a statistically significant improvement in their care competence when compared to the Comparison Group, with a large effect size. Conclusion: Plan Cuidarte improves care competence in people with heart failure during the hospital-home transition. Based on the Theory of Transitions, this intervention has potential to be implemented in the discharge training aimed at this population segment. The trial protocol was registered in February 2024 under the following title: Effect of the Plan Cuidarte on the Caregiving Competence of People With Heart Failure, ID number NCT06309875 available at: https://clinicaltrials.gov/study/NCT06309875.

Discussion

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Cite This Study

Vallejo-Ramírez et al. (2026) conducted an RCT in Heart Failure (n=100). Plan Cuidarte (hospital-home transitional care nursing educational intervention) vs. Conventional discharge plan (usual care) was evaluated on Overall care competence score (measured by the Cuidar instrument, range 0-60) (Hedges' g 0.93 (Cohen's d 0.94), 95% CI 0.52-1.35, p=0.000).

synapsesocial.com/papers/6af88c410e4d8f4b089c1b5d https://doi.org/10.1590/1518-8345.8271.4942

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Effect exerted by a hospital-home transition plan for people with Heart Failure: a randomized clinical trial

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Effect exerted by a hospital-home transition plan for people with Heart Failure: a randomized clinical trial

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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