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