Process evaluation of a nurse-led transitional care model (Cardiolotse) within a randomized controlled trial aiming to improve care coordination for patients with cardiovascular diseases in Germany.

TL;DR

The Cardiolotse study evaluated a nurse-led transitional care model for post-discharge support in German cardiovascular patients. While nurses provided valued support and made ~12,500 patient contacts, implementation was limited by poor engagement with office-based physicians and no significant improvements in satisfaction scores between intervention and control groups.

Key findings

• Nurse-led transitional care program (Cardiolotsen) was well-received by patients with high satisfaction ratings and trustworthy patient-provider interactions
• Implementation challenge: only 10% of general practitioners and cardiologists maintained regular contact with the care coordinators, indicating poor cross-sectoral communication
• No significant differences in satisfaction scores between intervention and control groups regarding medical treatment or healthcare provider coordination
• Nurses provided consistent post-discharge health monitoring and therapy adherence support through ~12,500 patient contacts, but integration with office-based physicians remained problematic

Why this matters at the bedside

This process evaluation identifies that while nurse-led transitional care models can effectively support post-discharge cardiovascular patients, success depends critically on establishing communication pathways with primary and specialist care providers—a structural barrier that hindered this intervention's impact on care coordination satisfaction.