Evaluation of the Transitional Care Model

This project is a Randomized Controlled Trial (RCT) of the Transitional Care Model, a nurse-led hospital discharge and home follow-up program for chronically ill older adults, aimed at preventing health complications and re-hospitalizations.

本项研究是一项随机对照试验（RCT），旨在评估过渡期护理模型的有效性，该模型由护士主导，针对慢性病老年患者实施医院出院及家庭随访计划，旨在预防健康并发症及再次入院。