Int J Nurs Stud. 2025 Oct 23;174:105257. doi: 10.1016/j.ijnurstu.2025.105257. Online ahead of print.
ABSTRACT
BACKGROUND: The care transition intervention has been designed to guide users in supporting older adults during care transitions; however, there is little knowledge about its effectiveness in older adults with multiple chronic conditions.
OBJECTIVE: This study evaluated the effects of the care transition intervention in older adults with multiple chronic conditions.
DESIGN: A randomized intervention study with a mixed-methods design was conducted.
METHODS: The quantitative phase of the study was conducted using a randomized clinical trial on older patients with multiple chronic conditions referred to the Imam Khomeini Hospital in Sari (Mazandaran, Iran) in 2022-2024. Patients in the experimental group received the care transition intervention which involved implementing a patient-centered record, and providing education on medication self-management, warning signs of worsening health condition(s) and how react to them, and follow-up. Patients in the control group received routine hospital care. Quality of life and the number of hospital readmissions were assessed before the intervention, and at one, three, and six months after hospital discharge. The qualitative phase focused on understanding the experiences of patients and caregivers who had participated in the care transition intervention. Qualitative data were analyzed using conventional content analysis. Finally, after analyzing the data from the quantitative and qualitative phases, the quantitative findings were compared to the qualitative findings.
RESULTS: There was a statistically significant between group difference in Quality of life at one (control group: 69.28(8.64), experimental group: 64.36(10.82)), three (control group: 71.41(8.70), experimental group: 64.20(10.90)) and six months (control group: 72.21(8.93), experimental group: 64.29 (11.26)) after hospital discharge (P < 0.05). Also, hospital readmission in the control group was 73 % higher than the experimental group. The greatest effect of the intervention for quality of life (effect size = 0.77) and readmission (effect size = 0.63) was found six months after discharge. Qualitative findings support a beneficial effect of the care transition intervention on the quality of life and readmission in older adults.
CONCLUSIONS: Using the care transition intervention for older adults with multiple chronic conditions improves health-related outcomes and is associated with reduced disease burden and more satisfaction towards life in different physical, psychological, and social dimensions for them. Therefore, implementing the care transition intervention can be useful for patients, their families and the healthcare system.
REGISTRATION: This trial was registered at irct.behdasht.gov.ir (Identifier: IRCT20180930041185N3, Registration date: 2022-09-23) and the first participant was registered in December 2022.
PMID:41206990 | DOI:10.1016/j.ijnurstu.2025.105257
