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.
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.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Enrollment
120
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.
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.
18/F, Metro South Tower 1, 39 Wong Chuk Hang Road, Wong Chuk Hang, Hong Kong
Hong Kong, Hong Kong, Hong Kong
The primary outcome is the change in the Patient Activation Measure (PAM) between baseline and 3-month follow-up.
The PAM is a 13-item self-report questionnaire to measure patient activation level \[18\]. Patients can go through four levels of activation: (1) disengaged and overwhelmed, (2) becoming aware but still struggling, (3) taking action, and (4) maintaining behaviors and pushing further \[18\].PAM raw score can be calculated by adding all of the responses to the 13 questions \[18\]. This score is then converted into an activation score ranging from 0 = no activation to 100 = high activation using a scoresheet provided by Insignia Health.
Time frame: From baseline to 3-month follow up.
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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
The control group will receive the usual hospital discharge practice upon discharge.