NCT07458841

Nurse-Led Discharge Program and Primary Care Outcomes: A Proof-of-concept Cluster Randomized Controlled Trial

Effectiveness of the Nurse-led Discharge Interventions in Promoting Hospital Patients' Primary Health Care Outcomes on Discharge: A Proof-of-concept Cluster Randomized Controlled Trial

• Status: Not Yet Recruiting
• Phase: N/A
• Study type: Interventional
• Enrollment: 120 (estimated)
• Sponsor: The University of Hong Kong · Academic / Other
• Sex: All
• Age: —
• Healthy volunteers: Not accepted

Summary

The goal of this cluster randomized controlled trial is to evaluate whether a nurse-led primary health care (PHC) discharge intervention can improve patient activation and primary health care-related outcomes among hospitalized adult patients after discharge.

Detailed description

Chronic diseases account for approximately 74% of global deaths and remain the leading cause of morbidity and mortality worldwide and in Hong Kong, particularly ischemic heart disease, cerebrovascular disease, and diabetes-related complications. The growing burden of ageing populations and non-communicable diseases highlights the need to shift healthcare systems from secondary and tertiary care toward prevention-oriented primary health care (PHC). PHC serves as the first point of contact in a continuous healthcare process and is essential to a sustainable healthcare system. In response, Hong Kong is implementing a PHC reform through the establishment of District Health Centres to enhance population health and reduce pressure on public hospitals. Nurses, as the largest healthcare workforce, play a critical role in PHC delivery; however, nursing training in Hong Kong remains predominantly hospital-focused. Strengthening hospital nurses' roles in PHC-oriented discharge education may improve care continuity, patient self-management, and long-term health outcomes while reducing hospital readmissions and healthcare costs. The aims of study are as follows: 1. To determine the main effect of the Intervention vs. Control group on Patient Activation Measure at 3-month follow-up after discharge (Primary) 2. To assess the effects on secondary outcomes at 3-month and 6-month follow-ups 3. To identify mediators between intervention and outcomes to inform the potential mechanisms 4. To qualitatively explore subjects' perceptions of managing their own health conditions after leaving the hospital and their experience of following the primary healthcare discharge intervention suggested by nurses.

Conditions

• Primary Healthcare

Interventions

Type	Name	Description
BEHAVIORAL	Primary healthcare discharge education	The primary healthcare discharge education begins by identifying priorities to address related to patients' life situations (using the Instrument for Patient Capacity Assessment) and determining the patient's current level of activation (using the Patient Activation Measure). A discharge education guide developed by the research team helps to individualize the teaching according to the patient's priorities and activation level.
BEHAVIORAL	specially-designed health education leaflet	1. Introduction of the District Health Centres/Expresses; 2. Life Course Preventive Care Plan pamphlet; 3. Provide disease-specific discharge/rehabilitation advice and relevant health education materials with an emphasis on prevention and self-care management; 4. The hospital nurses will help discharge patients download and install the "HA Go" mobile app.
BEHAVIORAL	Patient discharge package	Subjects in the intervention group will receive the following items with instructions for use upon hospital discharge: 1. Blood pressure monitor 2. Blood glucose test strip 3. Soft ruler to measure weight circumference 4. Resistance bands for simple exercise
BEHAVIORAL	usual hospital discharge practice	The control group will receive the usual hospital discharge practice upon discharge.

Timeline

• Start date: 2026-03-01
• Primary completion: 2027-02-01
• Completion: 2027-06-01
• First posted: 2026-03-09
• Last updated: 2026-03-09

Locations

1 site across 1 country: Hong Kong