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Table 1 Description of activities of the transition nurse (TN)

From: Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial

Time of the transition Action of the TN Main contact Tool implemented
During the patient’s stay in hospital Collect data about the patient, his caregiver, his primary care physician, and current primary care providers; Medical team and social workers of the discharging hospital Transitional care file intended for the TN: hospital part
  Verify that the admission geriatric assessment has been carried out by the medical team and complete it if necessary;   
  Develop the discharge plan in collaboration with the physicians, nurses, physiotherapists, and social workers of the hospital.   
When the day of hospital discharge is set Check that the date of returning home is known by the patient, his caregiver, and the primary care physician; The patient's primary care physician  
  Check that the discharge summary and plan have been transmitted to the primary care physician;   
  Check the organisation of the transport if needed;   
  Check that a primary care physician visit is planned (at home or in office) during the month following discharge;   
  Prepare the handover sheet, which includes the meetings scheduled (medical exams, biological monitoring), the contacts scheduled with the TN (by telephone or home visit), the telephone number and timetable where the TN can be reached, and the contact information of the primary care providers.   
The day of hospital discharge Check that the prescriptions for the discharge care plan are written (medications, physical therapy, medical equipment, etc.); Patient and his caregiver Handover sheet intended for the patient and the primary care providers
  Explain the discharge plan to the patient or his caregiver;   
  Give the completed handover sheet to the patient or caregiver and verify that the visits scheduled are planned in accordance with the patient or caregiver's availability;   
  Check that the discharge plan will be implemented with the social worker;   
  Check that the inpatient nursing care plan, along with the medical discharge summary, is in the handover sheet.   
After hospital discharge: follow-up by home visit and telephone Verify the effective implementation of human and material aid; ask about difficulties and seek to resolve problems; Patient and his caregiver Primary care providers Geriatrician Transitional care file intended for the TN: home part
  Help to prevent the risk of falls by having a look at the environment at home;   
  Ensure good medication compliance; verify the autonomy and clinical status of the patient, and contact stakeholders (nurse, primary care physician, hospital physician) if necessary;   
  Retrieve the results of biological monitoring and of medical visits; answer questions from the patient and his caregiver;   
  Provide regular reports to the primary care providers (by completing the handover sheet) and to the geriatrician.