RESUMEN
BACKGROUND: home visits and telephone calls are two often used approaches in transitional care but their differential effects are unknown. OBJECTIVE: to examine the overall effects of a transitional care programme for discharged medical patients and the differential effects of telephone calls only. DESIGN: randomised controlled trial. SETTING: a regional hospital in Hong Kong. PARTICIPANTS: patients discharged from medical units fitting the inclusion criteria (n = 610) were randomly assigned to: control ('control', n = 210), home visits with calls ('home', n = 196) and calls only ('call', n = 204). INTERVENTION: the home groups received alternative home visits and calls and the call groups calls only for 4 weeks. The control group received two placebo calls. The nurse case manager was supported by nursing students in delivering the interventions. RESULTS: the home visit group (after 4 weeks 10.7%, after 12 weeks 21.4%) and the call group (11.8, 20.6%) had lower readmission rates than the control group (17.6, 25.7%). Significance differences were detected in intention-to-treat (ITT) analysis for the home and intervention group (home and call combined) at 4 weeks. In the per-protocol analysis (PPA) results, significant differences were found in all groups at 4 weeks. There was significant improvement in quality of life, self-efficacy and satisfaction in both ITT and PPA for the study groups. CONCLUSIONS: this study has found that bundled interventions involving both home visits and calls are more effective in reducing readmissions. Many of the transitional care programmes use all-qualified nurses, and this study reveals that a mixed skills model seems to bring about positive effects as well.