Effects of a Nurse-Coordinated Transitional Care Service on Self-Management, Functional Status, Psychological, and...

Transitioning from hospital to home presents substantial challenges for patients with chronic obstructive pulmonary disease (COPD), often leading to difficulties maintaining self-management, functional independence, and psychological well-being after discharge. Although transitional care programs are increasingly implemented, their effects on multidimensional patient-centered outcomes remain insufficiently examined. This study aimed to evaluate the effectiveness of a nurse-coordinated transitional care service for patients with COPD during the transition from hospital to home and to examine its broader implications for improving continuity of care and patient-centered outcomes within the healthcare system.

This randomized controlled trial was conducted in three university hospitals in South Korea between November 2022 and December 2024. A total of 465 patients were randomly assigned to either a nurse-coordinated transitional care intervention group or a usual care group. The intervention included structured self-management education during hospitalization, post-discharge home visits, and follow-up telephone consultations during the first month after discharge. Outcomes were assessed at baseline, 1 month, and 3 months. Statistical analyses included linear mixed-effects models for continuous outcomes and chi-square tests and independent t-tests for group comparisons.

Patients in the Transitional Care Group (TCG) showed marked improvements: disease awareness increased from 27.9% to 94.3% (vs. 35.7% in the Usual Care Group [UCG], RR = 2.64, 95% CI: 2.19-3.18, p < 0.001) and exercise adherence to 76.3% (vs. 43.0%, RR = 1.78, 95% CI: 1.49-2.11, p < 0.001). After adjusting for age, cognitive function declined in both groups but showed significantly smaller decreases in the TCG than in the UCG at 3 months (mean difference = -0.92, p < 0.001), and IADL demonstrated significantly better preservation in the TCG (mean difference = -1.77, p < 0.001). Self-efficacy declined in both groups but remained significantly higher in the TCG (mean difference = 2.65, p < 0.001). Anxiety and depression were significantly reduced in the TCG compared with the UCG (anxiety: -1.45, p < 0.001; depression: -2.72, p < 0.001). After adjusting for age, discharge preparedness and post-discharge management capacity were significantly higher in the TCG than in the UCG (adjusted mean differences = 3.25 and 4.93, respectively; both p < 0.001).

These findings indicate that nurse-coordinated transitional care enhances patients' self-management capacity and improves patient-centered outcomes during the transition from hospital to home.