Aim. To test the effects of a postdischarge transitional care programme among patients with coronary heart disease.
Background. Coronary heart disease is a leading cause of death worldwide. Effective postdischarge care can help patients maintain a healthy lifestyle and thereby control the risk factors. Transitional care is under-developed in mainland China.
Design. A randomised controlled trial.
Method. The control group (n = 100) received routine care and the study group (n = 100) received the postdischarge transitional care programme, which consisted of predischarge assessment, structured home visits and telephone follow-ups within four weeks after discharge. Subjects were recruited in 2002–2003, with data collected at baseline before discharge, two days and four and 12 weeks after discharge.
Results. Participants in the study group had significantly better understanding in diet, medications and health-related lifestyle behaviour at day 2 and in weeks 4 and 12 and better understanding in exercise at weeks 4 and 12. There were significant differences between the control and study groups in diet and health-related lifestyle at day 2 and weeks 4 and 12, in medication at weeks 4 and 12 and exercise at week 12. There was no difference in hospital readmission between the two groups. The study group was very satisfied with the care. There was no difference in willingness to pay for nurse follow-up services between groups.
Conclusion. This study is an original effort to establish and test a nurse-led transitional care model in China. Results demonstrate that transitional care is effective in mainland China, concurring with studies done elsewhere.
Relevance to clinical practice. This study has constructed a transitional care model for patients with coronary heart disease in the context of the Chinese population which is effective in enhancing healthy lifestyle among these patients.