A nurse-led, telehealth transitional care intervention for people with multimorbidity: a feasibility study
Authors: Davis Kate , Ramsey Imogen , Sharplin Greg , Eckert Marion , Shakib Sepehr 
Published: December 2024

Objective: We aimed to develop and test the feasibility of a nurse-led, telehealth transitional care intervention for people with multimorbidity.
Design and methods: A feasibility study, using quantitative and qualitative methods was conducted at an 800-bed acute metropolitan hospital from March 2021 to January 2022. Eligible participants were adult inpatients with multimorbidity. The intervention involved three stages: (1) baseline risk of readmission assessment and collaborative development of a Transition Action Plan; (2) transitional care coordination following hospital discharge, and (3) handover to the primary healthcare provider. A Transition Coordinator delivered the intervention with the aim of determining the intervention’s feasibility in a practice environment. Acceptability to patients was assessed using a feedback survey. Acceptability to staff was noted through recorded interactions, collaboration, and feedback.
Results: Twenty-one adults with a mean age of 78 years participated in the intervention. Participants had 3-10 comorbid chronic conditions, and the most common were hypertension (71%), other cardiovascular (66%), renal (52%), and diabetes (47%). Most patients (52%) were at medium risk of readmission and 38% were at high risk, however, only 24% of patients were readmitted. The study identified there is no routine risk of re-admission screening for patients with multimorbidity, and the intervention was found to be acceptable and feasible to patients, ward staff, and the multidisciplinary team.
Conclusion: The results indicated feasibility of a transitional care intervention for people with multimorbidity, and the need for routine risk of readmission screening for people with multimorbidity. Further research is required to determine if the intervention is cost-effective and associated with reduced rates of hospital readmission.
What is already known about the topic?

People with multimorbidity often receive fragmented health services, which may increase their risk of hospital readmission.
Internationally, Transitional Care Model interventions improve the transition experience from acute hospital care to the community and reduce short-term readmission rates, for people with multimorbidity.
Transitional Care Model interventions have shown improved health and economic benefits for older adults. However, these benefits have not been evaluated in Australia.

What this paper adds

This study provides evidence regarding the feasibility and acceptability of a low-cost, nurse-led, transitional care intervention to support people with multimorbidity transitioning from acute hospital care to home/community, in the Australian context.
The study identified high support needs of participants upon transition and provides preliminary evidence in favour of a fundamental shift from discharge planning to stratified transition planning for patients with multimorbidity.
Presently, on hospital admission, there is no systematic risk of readmission assessment or transition care planning and implementation for people with multimorbidity. This is a notable service gap requiring redress across South Australian Local Health Networks.