Samenvatting

Background: Older cardiac patients are at high risk of readmission and mortality. Transitional care interventions
(TCIs) might contribute to the prevention of adverse outcomes. The Cardiac Care Bridge program was a
randomized nurse-coordinated TCI combining case management, disease management and home-based
rehabilitation for hospitalized frail older cardiac patients. This qualitative study explored the experiences of patients’
participating in this study, as part of a larger process evaluation as this might support interpretation of the neutral
study outcomes. In addition, understanding these experiences could contribute to the design and application of
future transitional care interventions for frail older cardiac patients.
Methods: A generic qualitative approach was used. Semi-structured interviews were performed with 16 patients
≥70 years who participated in the intervention group. Participants were selected by gender, diagnosis, living
arrangement and hospital of inclusion. Data were analysed using thematic analysis. In addition, quantitative data
about intervention delivery were analysed.
Results: Three themes emerged from the data: 1) appreciation of care continuity; 2) varying experiences with
recovery and, 3) the influence of an existing care network. Participants felt supported by the transitional care
intervention as they experienced post-discharge support and continuity of care. The perceived contribution of the
program in participants’ recovery varied. Some participants reported physical improvements while others felt
impeded by comorbidities or frailty. The home visits by the community nurse were appreciated, although some
participants did not recognize the added value. Participants with an existing healthcare provider network preferred
to consult these providers instead of the providers who were involved in the transitional care intervention.
Conclusion: Our results contribute to an explanation of the neutral study of a nurse-coordinated transitional care
intervention. For future purpose, it is important to identify which patients might benefit most from TCIs.
Furthermore, the intensity and content of TCIs could be more personalized by tailoring interventions to older
cardiac patients’ needs, considering their frailty, self-management skills and existing formal and informal caregiver
networks.