A randomized controlled trial of a nurse-led case management programme for hospital-discharged older adults with co-morbidities

AIM: To examine the effects of a nurse-led case management programme for hospital-discharged older adults with co-morbidities. BACKGROUND: The most significant chronic conditions today involve diseases of the cardiovascular, respiratory, endocrine and renal systems. Previous studies have suggested that a nurse-led case management approach using either telephone follow-ups or home visits was able to improve clinical and patient outcomes for patients having a single, chronic disease, while the effects for older patients having at least two long-term conditions are unknown. A self-help programme using motivation and empowerment approaches is the framework of care in the study. DESIGN: Randomized controlled trial. METHOD: The study was conducted from 2010–2012. Older patients having at least two chronic diseases were included for analysis. The participants were randomized into three arms: two study groups and one control group. Data were collected at baseline and at 4 and 12 weeks later. RESULTS: Two hundred and eighty-one patients completed the study. The interventions demonstrated significant differences in hospital readmission rates within 84 days post discharge. The two intervention groups had lower readmission rates than the control group. Patients in the two study arms had significantly better self-rated health and self-efficacy. There was significant difference between the groups in the physical composite score, but no significant difference in mental component score in SF-36 scale. CONCLUSION: The postdischarge interventions led by the nurse case managers on self-management of disease using the empowerment approach were able to provide effective clinical and patient outcomes for older patients having co-morbidities.