A Unified Framework for Nurse-Led Transitional Care Outcomes

Thesis Abstract

In the context of escalating readmission rates and fragmented care transitions, this study investigates nurse-led transitional care as a unified framework to optimize patient outcomes across the health continuum. The problem addressed is the lack of an integrated model that coherently aligns nursing-led transitional interventions with measurable outcomes, thereby enabling consistent care delivery and improved patient trajectories from hospital discharge to community or home-based care. The aim is to develop and validate a unified framework for nurse-led transitional care outcomes that synthesizes process, outcome, and contextual factors to guide practice, education, and policy. Specific objectives are (1) to delineate core components of nurse-led transitional care across acute, chronic, and primary care settings; (2) to identify determinants of successful transitions at patient, provider, and system levels; (3) to examine the relationship between transitional care processes and patient-reported outcomes (symptom burden, functional status, and satisfaction) and objective outcomes (30-day readmission, emergency department visits, and adherence); (4) to integrate theoretical perspectives from the Chronic Care Model and the Transitional Care Model into a coherent framework; and (5) to validate the framework using mixed-method data from multiple care settings. The methodology adopts a sequential explanatory mixed-method design. The quantitative phase targets a multicenter cohort of adult patients (n = 1,200) discharged to home or community care, sampled from five tertiary hospitals and affiliated primary care clinics. Data will be collected via standardized instruments including the Care Transitions Measure (CTM-15), the EQ-5D-5L for health-related quality of life, and medical record-derived outcomes (readmission within 30 days, primary care follow-up within 14 days, and medication reconciliation adequacy). Multilevel structural equation modeling (SEM) will assess relationships among transitional care processes, mediators (self-management capacity, social support, health literacy), and outcomes, controlling for age, comorbidity, and socio-economic status. The qualitative phase will purposively sample 40 patients and 20 nurse care coordinators from participating sites to explore experiential dimensions of transitions. Audio-recorded semi-structured interviews will be transcribed and analyzed using thematic analysis, with coding guided by the unified framework constructs. Integration of quantitative and qualitative findings will occur at the interpretation stage to refine the framework. The anticipated findings include (a) identification of a core set of transitional care processes that consistently predict improved patient-reported and objective outcomes; (b) quantification of indirect effects through mediators such as self-efficacy and health literacy, clarifying pathways from process to outcome; (c) evidence that organizational context and interprofessional collaboration moderate the effectiveness of nurse-led interventions; and (d) a validated framework that harmonizes elements from the Chronic Care Model and the Transitional Care Model into a practical, scalable construct for clinical practice and policy implementation. The study is expected to reveal variations in framework applicability across settings, with hospital-to-home transitions demonstrating stronger associations between structured discharge planning and reduced 30-day readmissions, whereas community-based transitions emphasize ongoing monitoring and caregiver engagement. Contribution to knowledge includes the provision of a theoretically grounded, empirically validated unified framework that (i) synthesizes disparate transitional care elements into a coherent model; (ii) operationalizes the framework for measurement and evaluation in diverse health systems; and (iii) offers guidance for nurse-led program design, education curricula, and policy initiatives aimed at standardizing transitional care delivery. The main conclusion will articulate the framework’s utility in achieving consistency, equity, and quality in nurse-led transitions, while recommendations will address implementation strategies, requisite training for nurse care coordinators, data infrastructure needs, and directions for future research, including cross-national validation and economic evaluation of framework-enabled transitional care programs.