Discharged older adult inpatients are often administered a variety of drugs. However, many only take roughly half of their medications and many discontinue treatment. Nursing strategies might enhance medication adherence in this group. The goal of this research is to assess the efficacy of nurse-led transitional care strategies after hospital discharge of older patients versus usual care in enhancing cognitive processes, physical performance, signs of depression and stress, perceptions of social support, patient satisfaction, and the costs associated with medical service use among older patients with multiple chronic conditions and signs of depression. Three sites in Ontario, Canada were used for a pragmatic multi-site randomized controlled research. Individuals were randomly assigned to either an intervention group or a control (normal care) group. 127 people over the age of 65 were discharged from the hospital with several chronic conditions and signs of depression. Over six months, a Registered Nurse provided individualized care through cell phone follow-up, house visits, and device navigation help as part of an evidence-based, patient-centered intervention. The main result was a shift in cognitive performance between the first and sixth months. Alterations in physical performance, depressed symptoms, stress, and social support perceived, patient satisfaction, and the cost of health care usage were secondary results measured from baseline to six months. ANCOVA modeling was used for the intention-to-treat analysis.
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