Advanced Practice Nurse–Led Transitional Care Bundles and Early Post-Discharge Outcomes in Complex Chronic Patients: A Quasi-Experimental Evaluation
DOI:
https://doi.org/10.61978/curatio.v2i3.1413Keywords:
Transitional Care, Advanced Practice Nurse, Hospital Discharge, Care Coordination, Readmission, Patient-Reported OutcomesAbstract
Transitions from hospital to home are a critical period for patients with complex chronic conditions, often marked by fragmented care, poor coordination, and preventable acute-care utilization. Advanced practice nurses (APNs) are increasingly positioned to address these gaps through structured transitional care. This study evaluated the impact of an APN-led Transitional Care Bundle on early post-discharge outcomes among complex chronic patients. A quasi-experimental evaluation was conducted among adults with complex chronic conditions—including heart failure, COPD, and diabetes—discharged from hospital to home. The intervention comprised a structured Transitional Care Bundle coordinated by APNs, incorporating mandatory components (individualized education, medication reconciliation, service access facilitation, and early post-discharge follow-up) and optional components based on patient need. Outcomes were compared with usual care using electronic health records, program logs, and patient surveys. Patients receiving the APN-led bundle experienced significantly lower 30-day readmissions and emergency department visits, higher completion of discharge medication reconciliation, and substantially improved seven-day follow-up rates. Patient-reported transition quality (CTM-15) was significantly higher, reflecting improved preparedness and self-management support. These findings support APNs as coordinators of standardized transitional care bundles, with future research needed on long-term outcomes, cost implications, and scalability.
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