Abstract

To evaluate the effects of a hospital-community partnership transitional program among patients with coronary heart disease. This was a randomized controlled trial with 236 patients who were randomized into two groups. The patients in the control group received the usual care. In contrast, the patients in the study group received the transitional care program. The data were collected at the baseline, 30 days, and 90 days after discharge. The primary outcomes were the 30 and 90 day readmission rates after discharge. The secondary outcomes included the quality-of-care transitions, medicine adherence, and chronic disease self-efficacy. The findings indicated that: (i) the patients in the study group reported significantly lower 30 and 90 day readmission rates after their discharge than those in the control group; (ii) statistically significant differences were found in the quality-of-care transitions at 30 days postdischarge between the two groups as the patients in the study group reported significantly higher quality-of-care transitions, compared to those in the control group; and (iii) the patients in the study group reported significantly higher scores in medication adherence and chronic disease self-efficacy at 30 and 90 days after discharge than those in the control group. This study is an original effort to establish and evaluate a hospital-community partnership transitional care program in patients with coronary heart disease in China and the findings have demonstrated its effects.

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