Nurse-coordinated, transitional care intervention for hospitalised older adults in a frailty registry: The...

The hospital to home transition is a critical journey for older adults, often leading to health decline and increased healthcare utilisation. Frailty amplifies these risks, making effective support strategies during the transition home essential to improving outcomes and reducing the risk of rehospitalisation.

To evaluate the feasibility and acceptability of a nurse-coordinated, transitional care intervention for older adults enrolled in a frailty registry transitioning from hospital to home.

Prospective, non-randomised, single-arm, Phase I feasibility and acceptability trial within a cohort study.

Patients were eligible if: aged 65 years and over, admitted under Geriatric, Aged Care and Rehabilitation Services at two metropolitan hospitals, enrolled in the Western Sydney Clinical Frailty Registry, and discharging home. The intervention, titled as the 'Nurse Navigator', included nurse-coordinated, phone-based, patient-centred discharge communication initiated during the transfer from hospital to home. The primary outcome was the feasibility and acceptability of the intervention, assessed by the proportion of participants who were able to agree with and achieve the patient-centred priorities.

A total of 127 participants were recruited, of whom 106 completed the intervention. Participants were mostly female (57%), with a mean age of 80.4 years. Intervention fidelity was high. One hundred and five (99%) participants able to agree to the three patient-centred priorities, and 99 (93%) able to achieve these three priorities.

There was high feasibility and acceptability of a nurse-coordinated, transitional care intervention for complex older adults transitioning from hospital to home. The high level of engagement and achievement of patient-centred priorities highlights the positive potential of tailored communication strategies to support safe and effective transitions. These results suggest implementation projects, or Phase II or III randomised controlled trials, are promising to improve patient-reported outcomes.

The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), trial ID: ACTRN12624000795594. Registered and updated 28th July 2024. First participant recruited August 2024, and last participant recruited February 2025.