Aims: To evaluate the effect of a nurse-coordinated hospital-initiated transitional care programme on hypertension control for older people with diabetes in China. Design: A cluster randomized controlled trial. Methods: A total of 10 wards (clusters) of four acute care hospitals participated in the trial. They were randomly assigned to the intervention group or the control group. A total of 270 participants (135 in each group) were recruited from these wards. Data were collected between June 2016 - June 2017. Participants in the intervention group received a 6-month hospital to home transitional care programme coordinated by discharge nurses and community nurses. The programme comprised self-management education, lifestyle changes, individualized medication treatment, structured telephone support, and primary care visits. Outcomes were measured at baseline, and 3 months and 6 months from the baseline. Results: The mean age was 70.9 (SD 5.8) years and 55% of participants were men. The intervention group demonstrated a statistically significant decrease in mean systolic blood pressure of 10.7 mmHg and mean diastolic blood pressure of 4.1 mmHg compared with the control group. The findings also demonstrated significant improvements in HbA1c, hypertension knowledge, diabetes knowledge, treatment adherence, quality of life, hospital readmission, and emergency department visits in the intervention group compared with the control group. However, no significant differences in adverse events were observed between the two groups. Conclusions: A hospital-initiated and nurse-coordinated transitional care intervention improves hypertension control and reduces hospital readmissions for older people with diabetes. Impact: Lack hospital to home transitional care for hospitalized older people with hypertension and diabetes can result in high readmission rates and emergency department visits. A hospital-initiated and nurse-coordinated transitional care intervention built on collaboration between acute care hospitals and community health centres results in improved hypertension control and reduced readmissions for older people with diabetes and other chronic conditions. An integrated and well-coordinated care services between acute care hospitals and community health centres can strengthen the primary care approach to supporting self-management of hypertension, diabetes, and other ageing-associated health conditions for community-dwelling older people. Trial registration: The trial was registered with the Australia New Zealand Clinical Trials Registry (ID: ACTRN12617001352392).
- Cluster randomized controlled trial
- Integrated care
- Nurse coordinator
- Primary care
- Transitional care