The nurse-coordinated cardiac care bridge transitional care programme

Authors Patricia Jepma , Lotte Verweij , Bianca M Buurman , Michel S Terbraak , Sara Daliri , Corine HM Latour , Gerben ter Riet , Fatma Karapinar-Çarkit , Jill Dekker , José L Klunder , Su-San Liem , Arno HM Moons , Ron JG Peters , Wilma JM Scholte op Reimer
Published in Age and Ageing
Publication date 2021
Research groups Proactive care for older people living at home
Type Article


Background: after hospitalisation for cardiac disease, older patients are at high risk of readmission and death. Objective: the cardiac care bridge (CCB) transitional care programme evaluated the impact of combining case management, disease management and home-based cardiac rehabilitation (CR) on hospital readmission and mortality. Design: single-blind, randomised clinical trial. Setting: the trial was conducted in six hospitals in the Netherlands between June 2017 and March 2020. Community-based nurses and physical therapists continued care post-discharge. Subjects: cardiac patients ≥ 70 years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6 months. Methods: the intervention group received a comprehensive geriatric assessment-based integrated care plan, a face-to-face handover with the community nurse before discharge and follow-up home visits. The community nurse collaborated with a pharmacist and participants received home-based CR from a physical therapist. The primary composite outcome was first all-cause unplanned readmission or mortality at 6 months. Results: in total, 306 participants were included. Mean age was 82.4 (standard deviation 6.3), 58% had heart failure and 92% were acutely hospitalised. 67% of the intervention key-elements were delivered. The composite outcome incidence was 54.2% (83/153) in the intervention group and 47.7% (73/153) in the control group (risk differences 6.5% [95% confidence intervals, CI -4.7 to 18%], risk ratios 1.14 [95% CI 0.91-1.42], P = 0.253). The study was discontinued prematurely due to implementation activities in usual care. Conclusion: in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months.

Language English
Published in Age and Ageing
Year and volume 50 6
Key words cardiac rehabilitation, cardiology, case management, disease management, transitional care
Digital Object Identifier 10.1093/ageing/afab146
Page range 2105-2115

Proactive care for older people living at home