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Table 2 Time frame and components of the Cardiac Care Bridge program and the control group

From: The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality

Time Frame Intervention component Baseline – outcome measures Professionals involved Intervention Control
Clinical phase
  ≤ 72 h after hospital admission CGA a Baseline CRNb X X
  ≤ 72 h after hospital admission Integrated care plan   CRNb X  
 During hospital stay Geriatric team consultation in case of ≥ 5 identified health issues or ≥ 1 psychological issue   CRNb, CNSc, geriatrician X  
Discharge phase
 Before hospital discharge In-person handover of the CGAa, integrated care plan and medical treatment plan   CRNb, CCRNd X  
 Before hospital discharge Visit of CCRNd to participant   CCRNd X  
 At discharge Medical discharge letter   Cardiologist, GPe, CCRNd X X
Post-clinical phase
  ≤ 2 days after hospital discharge Home visit 1. Medication reconciliation and integrated care plan   CCRNd X  
  ≤ 1 week Home visit 2. Intake home based cardiac rehabilitation and integrated care plan   CCRNd, PTf X  
 Week 1 Two home-based cardiac rehabilitation sessions   PTf X  
 Week 2 Two home-based cardiac rehabilitation sessions   PTf X  
 Week 3 Home visit 3. lifestyle promotion and self-management   CCRNd PTf X X  
Two home-based cardiac rehabilitation sessions   PTf X  
 Week 4 Two home-based cardiac rehabilitation sessions   PTf X  
 Week 5 Two home-based cardiac rehabilitation sessions     
 Week 6 Home visit 4. Evaluation of integrated care plan and home-based cardiac rehabilitation   CCRNd PTf X X  
Two home-based cardiac rehabilitation sessions     
  ≤ 12 weeks Home visit 5. If indicated by the CCRNb     
 3 months   Follow-up telephone Research Nurse X X
 6 months   Follow-up home visit Research Nurse X X
 12 months   Follow-up telephone Research Nurse X X
  1. aComprehensive Geriatric Assessment (CGA)
  2. bCardiac Research Nurse (CRN)
  3. cClinical Nurse Specialist in geriatrics (CNS)
  4. dCommunity Care Registered Nurse (CCRN)
  5. eGeneral Practitioner (GP)
  6. fPhysical therapist (PT)