Nurse-Led Discharge Program and Primary Care Outcomes: A Proof-of-concept Cluster Randomized Controlled Trial
For patients and families
In plain language
An automatic summary of structured registry data. It is an orientation aid, not a substitute for the official protocol or a physician assessment.
- What is being studied
- The protocol lists: Primary healthcare discharge education, specially-designed health education leaflet, Patient discharge package, usual hospital discharge practice.
- Who it may be relevant to
- Registry conditions: Primary Healthcare. Basic parameters: No limits · All.
- What needs checking
- Age, condition and sex are only basic indicators. Prior treatment, laboratory values and other mandatory requirements appear in the eligibility criteria below.
- Where it takes place
- Hong Kong
- Next step
- Save the trial, show it to the treating physician, and confirm current recruitment with the study center. Costs, documents and travel →
Unsure about the terms? Read our patient guide →
Official title
Effectiveness of the Nurse-led Discharge Interventions in Promoting Hospital Patients' Primary Health Care Outcomes on Discharge: A Proof-of-concept Cluster Randomized Controlled Trial
Overview
The goal of this cluster randomized controlled trial is to evaluate whether a nurse-led primary health care (PHC) discharge intervention can improve patient activation and primary health care-related outcomes among hospitalized adult patients after discharge.
Detailed description
Chronic diseases account for approximately 74% of global deaths and remain the leading cause of morbidity and mortality worldwide and in Hong Kong, particularly ischemic heart disease, cerebrovascular disease, and diabetes-related complications. The growing burden of ageing populations and non-communicable diseases highlights the need to shift healthcare systems from secondary and tertiary care toward prevention-oriented primary health care (PHC).
PHC serves as the first point of contact in a continuous healthcare process and is essential to a sustainable healthcare system. In response, Hong Kong is implementing a PHC reform through the establishment of District Health Centres to enhance population health and reduce pressure on public hospitals. Nurses, as the largest healthcare workforce, play a critical role in PHC delivery; however, nursing training in Hong Kong remains predominantly hospital-focused. Strengthening hospital nurses' roles in PHC-oriented discharge education may improve care continuity, patient self-management, and long-term health outcomes while reducing hospital readmissions and healthcare costs.
The aims of study are as follows:
1. To determine the main effect of the Intervention vs. Control group on Patient Activation Measure at 3-month follow-up after discharge (Primary) 2. To assess the effects on secondary outcomes at 3-month and 6-month follow-ups 3. To identify mediators between intervention and outcomes to inform the potential mechanisms 4. To qualitatively explore subjects' perceptions of managing their own health conditions after leaving the hospital and their experience of following the primary healthcare discharge intervention suggested by nurses.
Interventions
- Behavioral Primary healthcare discharge education
The primary healthcare discharge education begins by identifying priorities to address related to patients' life situations (using the Instrument for Patient Capacity Assessment) and determining the patient's current level of activation (using the Patient Activation Measure). A discharge education guide developed by the research team helps to individualize the teaching according to the patient's priorities and activation level. - Behavioral specially-designed health education leaflet
1. Introduction of the District Health Centres/Expresses; 2. Life Course Preventive Care Plan pamphlet; 3. Provide disease-specific discharge/rehabilitation advice and relevant health education materials with an emphasis on prevention and self-care management; 4. The hospital nurses will help discharge patients download and install the "HA Go" mobile app. - Behavioral Patient discharge package
Subjects in the intervention group will receive the following items with instructions for use upon hospital discharge: 1. Blood pressure monitor 2. Blood glucose test strip 3. Soft ruler to measure weight circumference 4. Resistance bands for simple exercise - Behavioral usual hospital discharge practice
The control group will receive the usual hospital discharge practice upon discharge.
Primary outcome measures
- The primary outcome is the change in the Patient Activation Measure (PAM) between baseline and 3-month follow-up. [Time frame: From baseline to 3-month follow up.]
Eligibility criteria
Inclusion criteria
- Hong Kong residents aged ≥18 years
- Able to read and communicate in Chinese (Cantonese or Mandarin)
- Being hospitalized for more than 24 hours
- Stable medical condition upon hospital discharge
Exclusion criteria
- Having a history of psychiatric/psychological disease or currently on regular psychotropic medications
- Currently participating in other primary healthcare programmes
Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.
Healthy volunteers: No
Study design
- Allocation
- Randomized
- Model
- Parallel assignment
- Masking
- Open label
- Primary purpose
- Health services research
Study locations
Hong Kong · 1 center
- 18/F, Metro South Tower 1, 39 Wong Chuk Hang Road, Wong Chuk Hang, Hong Kong — Hong Kong
Publications
- Merkow RP, Kaji AH, Itani KMF. The CONSORT Framework. JAMA Surg. 2021 Sep 1;156(9):877-878. doi: 10.1001/jamasurg.2021.0549. No abstract available. PMID 33825818
- Rowland E, Conolly A. A worked example of contextualising and using reflexive thematic analysis in nursing research. Nurse Res. 2024 Dec 11;32(4):17-27. doi: 10.7748/nr.2024.e1924. Epub 2024 Aug 29. PMID 39206491
- Duarte MP, Vieira FA, Baiao VM, Monteiro JS, Ferreira AP, Inda-Filho AJ, Nobrega OT, Ribeiro HS. The 10-Item Physical Function Scale as a Sarcopenia Screening Tool for Patients on Hemodialysis. J Ren Nutr. 2024 Nov;34(6):546-551. doi: 10.1053/j.jrn.2024.05.012. Epub 2024 Jun 5. PMID 38848807
- Ingram PB 4th, Clarke E, Lichtenberg JW. Confirmatory Factor Analysis of the Perceived Stress Scale-4 in a Community Sample. Stress Health. 2016 Apr;32(2):173-6. doi: 10.1002/smi.2592. Epub 2014 Jul 4. PMID 24995556
- Adzrago D, Walker TJ, Williams F. Reliability and validity of the Patient Health Questionnaire-4 scale and its subscales of depression and anxiety among US adults based on nativity. BMC Psychiatry. 2024 Mar 18;24(1):213. doi: 10.1186/s12888-024-05665-8. PMID 38500115
- Shmueli A. The Visual Analog rating Scale of health-related quality of life: an examination of end-digit preferences. Health Qual Life Outcomes. 2005 Nov 14;3:71. doi: 10.1186/1477-7525-3-71. PMID 16285884
- Weiss ME, Piacentine LB. Psychometric properties of the Readiness for Hospital Discharge Scale. J Nurs Meas. 2006 Winter;14(3):163-80. doi: 10.1891/jnm-v14i3a002. PMID 17278337
- Benson T, Potts HWW, Bark P, Bowman C. Development and initial testing of a Health Confidence Score (HCS). BMJ Open Qual. 2019 Jun 7;8(2):e000411. doi: 10.1136/bmjoq-2018-000411. eCollection 2019. PMID 31259277
Identifiers
NCT: NCT07458841 · currently not available