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Objective: To investigate patients’ post-discharge difficulties through periodic telephone follow-ups from the hospital nurse to the care manager.
Methods: The effects of the intervention will be examined using a randomized controlled trial and prospective randomized, open blinded-endpoint evaluation. This research targets patients who are older than 65 years of age, require a care manager and leave the hospital for their homes or residential care facilities. The participants, 50 pairs of patients and care managers, will provide consent for this study. In the intervention group, telephone follow ups from the hospital nurse to the care manager will be carried out three times: one week, one month, and two months after discharge; the control group will follow standard protocols. A self-administered questionnaire survey about difficulties after discharge will be conducted twice (one week and two months after discharge), and the results will be compared between groups. In addition, 10 care managers from the intervention group will be interviewed, and the contents will be analyzed as a process evaluation.
Discussion: The novelty of this study is that it strengthens the cooperation between the staff using telephone follow-ups and the evaluates the patients’ unease and frustration. If effective, the telephone follow-up could be systematized and incorporated into standard care. Furthermore, the appropriate period, timing, and frequency of telephone follow-ups may become clear with the study. In terms of future research, the development of a new follow up program based on the results of this study and the examination of its effects will contribute to the development of the follow-up system.
Trial registration: This study was registered with the UMIN Clinical Trials Registry on May 7, 2018 (ID: UMIN000032251).