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NCT Number: NCT07458841

Nurse-Led Discharge Program and Primary Care Outcomes: A Proof-of-concept Cluster Randomized Controlled Trial

The goal of this cluster randomized controlled trial is to evaluate whether a nurse-led primary health care (PHC) discharge intervention can improve patient activation and primary health care-related outcomes among hospitalized adult patients after discharge.

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Key information

Conditions

Primary Healthcare

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

18/F, Metro South Tower 1, 39 Wong Chuk Hang Road, Wong Chuk Hang, Hong Kong

Hong Kong, 000000

Location contact

Siu Long Chau, PhD

CONTACT

[email protected]

+852 6700 9987

Siu Long Chau, PhD

PRINCIPAL_INVESTIGATOR

About this study

Chronic diseases account for approximately 74% of global deaths and remain the leading cause of morbidity and mortality worldwide and in Hong Kong, particularly ischemic heart disease, cerebrovascular disease, and diabetes-related complications. The growing burden of ageing populations and non-communicable diseases highlights the need to shift healthcare systems from secondary and tertiary care toward prevention-oriented primary health care (PHC).

PHC serves as the first point of contact in a continuous healthcare process and is essential to a sustainable healthcare system. In response, Hong Kong is implementing a PHC reform through the establishment of District Health Centres to enhance population health and reduce pressure on public hospitals. Nurses, as the largest healthcare workforce, play a critical role in PHC delivery; however, nursing training in Hong Kong remains predominantly hospital-focused. Strengthening hospital nurses' roles in PHC-oriented discharge education may improve care continuity, patient self-management, and long-term health outcomes while reducing hospital readmissions and healthcare costs.

The aims of study are as follows:

  • To determine the main effect of the Intervention vs. Control group on Patient Activation Measure at 3-month follow-up after discharge (Primary)
  • To assess the effects on secondary outcomes at 3-month and 6-month follow-ups
  • To identify mediators between intervention and outcomes to inform the potential mechanisms
  • To qualitatively explore subjects' perceptions of managing their own health conditions after leaving the hospital and their experience of following the primary healthcare discharge intervention suggested by nurses.

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

  • Hong Kong residents aged ≥18 years
  • Able to read and communicate in Chinese (Cantonese or Mandarin)
  • Being hospitalized for more than 24 hours
  • Stable medical condition upon hospital discharge

Exclusion criteria

  • Having a history of psychiatric/psychological disease or currently on regular psychotropic medications
  • Currently participating in other primary healthcare programmes

Treatment and study plan

Primary healthcare discharge education

Behavioral

The primary healthcare discharge education begins by identifying priorities to address related to patients' life situations (using the Instrument for Patient Capacity Assessment) and determining the patient's current level of activation (using the Patient Activation Measure). A discharge education guide developed by the research team helps to individualize the teaching according to the patient's priorities and activation level.

specially-designed health education leaflet

Behavioral
  • Introduction of the District Health Centres/Expresses;
  • Life Course Preventive Care Plan pamphlet;
  • Provide disease-specific discharge/rehabilitation advice and relevant health education materials with an emphasis on prevention and self-care management;
  • The hospital nurses will help discharge patients download and install the "HA Go" mobile app.

Patient discharge package

Behavioral

Subjects in the intervention group will receive the following items with instructions for use upon hospital discharge:

  • Blood pressure monitor
  • Blood glucose test strip
  • Soft ruler to measure weight circumference
  • Resistance bands for simple exercise

usual hospital discharge practice

Behavioral

The control group will receive the usual hospital discharge practice upon discharge.

Primary outcomes

  1. The primary outcome is the change in the Patient Activation Measure (PAM) between baseline and 3-month follow-up.

    Time frame: From baseline to 3-month follow up.

    The PAM is a 13-item self-report questionnaire to measure patient activation level [18]. Patients can go through four levels of activation: (1) disengaged and overwhelmed, (2) becoming aware but still struggling, (3) taking action, and (4) maintaining behaviors and pushing further [18].PAM raw score can be calculated by adding all of the responses to the 13 questions [18]. This score is then converted into an activation score ranging from 0 = no activation to 100 = high activation using a scoresheet provided by Insignia Health.

Study contacts

Contact information is provided by the study sponsor or research team.

Siu Long Chau, PhD

CONTACT

[email protected]

+852 6700 9987

Sponsors and collaborators

Lead sponsor

The University of Hong Kong

Other

Collaborators

  • Queen Mary Hospital, Hong Kong

Registry information

Official study title

Effectiveness of the Nurse-led Discharge Interventions in Promoting Hospital Patients' Primary Health Care Outcomes on Discharge: A Proof-of-concept Cluster Randomized Controlled Trial

Important dates

Study start
2026
Primary completion
2027
Study completion
2027
First posted
Mar 9, 2026
Registry last updated
Mar 9, 2026

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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