Table 4 Score distribution for CAS characteristics, interdependencies, and outcomes

Learning

• 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.

Interconnections

• Advanced practice nurses contacted patients after discharge.

• Case managers met with patients after each physician visit.

Self-organization

• 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.

Co-evolution

(none)

Emergence

(none)

Affordances

• Patients were provided personal telecare units.

• Patients were given discharge forms in one of three languages.

Processes

• 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

(not applicable)