The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality

Verweij, L.; Jepma, P.; Buurman, B. M.; Latour, C. H. M.; Engelbert, R. H. H.; ter Riet, G.; Karapinar-Çarkit, F.; Daliri, S.; Peters, R. J. G.; Scholte op Reimer, W. J. M.

doi:10.1186/s12913-018-3301-9

Table 2 Time frame and components of the Cardiac Care Bridge program and the control group

From: The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality

Time Frame	Intervention component	Baseline – outcome measures	Professionals involved	Intervention	Control
Clinical phase
≤ 72 h after hospital admission	CGA ^a	Baseline	CRN^b	X	X
≤ 72 h after hospital admission	Integrated care plan		CRN^b	X
During hospital stay	Geriatric team consultation in case of ≥ 5 identified health issues or ≥ 1 psychological issue		CRN^b, CNS^c, geriatrician	X
Discharge phase
Before hospital discharge	In-person handover of the CGA^a, integrated care plan and medical treatment plan		CRN^b, CCRN^d	X
Before hospital discharge	Visit of CCRN^d to participant		CCRN^d	X
At discharge	Medical discharge letter		Cardiologist, GP^e, CCRN^d	X	X
Post-clinical phase
≤ 2 days after hospital discharge	Home visit 1. Medication reconciliation and integrated care plan		CCRN^d	X
≤ 1 week	Home visit 2. Intake home based cardiac rehabilitation and integrated care plan		CCRN^d, PT^f	X
Week 1	Two home-based cardiac rehabilitation sessions		PT^f	X
Week 2	Two home-based cardiac rehabilitation sessions		PT^f	X
Week 3	Home visit 3. lifestyle promotion and self-management		CCRN^d PT^f	X X
Week 3	Two home-based cardiac rehabilitation sessions		PT^f	X
Week 4	Two home-based cardiac rehabilitation sessions		PT^f	X
Week 5	Two home-based cardiac rehabilitation sessions
Week 6	Home visit 4. Evaluation of integrated care plan and home-based cardiac rehabilitation		CCRN^d PT^f	X X
Week 6	Two home-based cardiac rehabilitation sessions
≤ 12 weeks	Home visit 5. If indicated by the CCRN^b
3 months		Follow-up telephone	Research Nurse	X	X
6 months		Follow-up home visit	Research Nurse	X	X
12 months		Follow-up telephone	Research Nurse	X	X

^aComprehensive Geriatric Assessment (CGA)
^bCardiac Research Nurse (CRN)
^cClinical Nurse Specialist in geriatrics (CNS)
^dCommunity Care Registered Nurse (CCRN)
^eGeneral Practitioner (GP)
^fPhysical therapist (PT)

Back to article page

ISSN: 1472-6963

Contact us

General enquiries: journalsubmissions@springernature.com

BMC Health Services Research

Contact us