Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention

Authors Patricia Jepma, Corine HM Latour, Iris HJ ten Barge, Lotte Verweij, Ron JG Peters, Wilma JM Scholte op Reimer, Bianca M Buurman
Published in BMC Health Services Research
Publication date 2021
Research groups Proactive care for older people living at home
Type Article


Background: Older cardiac patients are at high risk of readmission and mortality. Transitional care interventions (TCIs) might contribute to the prevention of adverse outcomes. The Cardiac Care Bridge program was a randomized nurse-coordinated TCI combining case management, disease management and home-based rehabilitation for hospitalized frail older cardiac patients. This qualitative study explored the experiences of patients’ participating in this study, as part of a larger process evaluation as this might support interpretation of the neutral study outcomes. In addition, understanding these experiences could contribute to the design and application of future transitional care interventions for frail older cardiac patients. Methods: A generic qualitative approach was used. Semi-structured interviews were performed with 16 patients ≥70 years who participated in the intervention group. Participants were selected by gender, diagnosis, living arrangement and hospital of inclusion. Data were analysed using thematic analysis. In addition, quantitative data about intervention delivery were analysed. Results: Three themes emerged from the data: 1) appreciation of care continuity; 2) varying experiences with recovery and, 3) the influence of an existing care network. Participants felt supported by the transitional care intervention as they experienced post-discharge support and continuity of care. The perceived contribution of the program in participants’ recovery varied. Some participants reported physical improvements while others felt impeded by comorbidities or frailty. The home visits by the community nurse were appreciated, although some participants did not recognize the added value. Participants with an existing healthcare provider network preferred to consult these providers instead of the providers who were involved in the transitional care intervention. Conclusion: Our results contribute to an explanation of the neutral study of a nurse-coordinated transitional care intervention. For future purpose, it is important to identify which patients might benefit most from TCIs. Furthermore, the intensity and content of TCIs could be more personalized by tailoring interventions to older cardiac patients’ needs, considering their frailty, self-management skills and existing formal and informal caregiver networks.

Language English
Published in BMC Health Services Research
Year and volume 21 1
Key words cardiac rehabilitation, cardiology, case management, disease management, frailty, nurses, physical therapists, qualitative research, transitional care
Digital Object Identifier 10.1186/s12913-021-06719-3

Proactive care for older people living at home