• Nurses used behavior skill training strategies with patients and encouraged their self-monitoring and use of external cognitive supports.|
• Nurses provided patients education on such things as vital signs, activities of daily living, coping skills, and signs and symptoms.
• Advanced practice nurses contacted patients after discharge.|
• Case managers met with patients after each physician visit.
• Physicians were alerted if patient values went outside normal range; if deemed necessary, physicians could ask patients to adjust medication use.|
• Nurses could modify or tailor the frequency of patient follow-up calls based on patient symptoms, knowledge, and needs.
• Patients were provided personal telecare units.|
• Patients were given discharge forms in one of three languages.
• An appointment reminder was mailed to patients 10 days prior to each appointment.|
• Patient discharge forms were electronically transferred to primary care nurses.
|Positive Intervention Effect Reported||18 (39%)||(not applicable)|