Welcome to the Current Issues section of the Journal of Transitional and Home Health Nursing. This section provides access to all published articles, categorized by volume and issue, and serves as a comprehensive resource for researchers, clinicians, and academicians in the field of transitional care and home health nursing.
Featured Articles in the Latest Issue
- Volume 2 (Issue 1) JANUARY- JUNE 2026
Research Articles
Nurse-Led Transitional Care Programs for Reducing 30-Day Hospital Readmissions Among Older Adults with Chronic Heart Failure
Vol.2(1); Pages:1-10. Published on April-2026
Abstract
The readmission of elderly patients with chronic heart failure in hospitals is one of the critical issues of transitional healthcare systems in the world. It is a prospective cohort study that assessed the efficacy of a leaderless transitional care model led by nurses aimed at assisting patients in the process of hospital-to-home transition. The program involved discharge education, medication reconciliation, home follow-up visits and home structured telephonic monitoring four weeks post discharge. Two tertiary hospitals were used to recruit 210 patients aged 65 years and above who were followed up over 30 days after discharge. Hospital readmission rates, medication adherence, symptom management, and patient satisfaction with home care services were used as outcome measures. Findings revealed a statistically significant difference in the number of readmission between participants who were provided with the nurse-led intervention and those who were provided with the traditional discharge procedures. Also, the patients had a boosted self-confidence in the management of heart failure symptoms and increased compliance with medication regimens. The results show how transitional nursing interventions are very crucial to the gap between hospital and home care settings. The adoption of structured nurse-led models of transitional care can be an effective intervention in enhancing continuity of care and decrease avoidable hospital use among the elderly with heart failure.
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Home-Based Telemonitoring for Post-Surgical Recovery in Community Nursing Practice
Vol.2(1); Pages:11-21. Published on April-2026
Abstract
The increasing demand of post-operative home care has led to healthcare systems seeking to identify technologies of telemonitoring to enhance safe recovery when not in a hospital. The study was a randomized controlled trial that aimed to determine the efficiency of a home-based tele monitoring program under the supervision of local health nurses to patients who have undergone major abdominal surgery. One hundred and sixty participants were randomly divided into two categories, i.e., the telemonitoring intervention group; and the conventional follow-up care group. The intervention involved remote monitoring of the vital signs, digital wound assessment, and daily nurse-led virtual visits during three weeks of recovery. The complication detected time, patient recovery progress, and unplanned hospital visits were all primary outcomes. The findings indicated that patients on telemonitoring had earlier detection of post-surgical complications with a much lower number of emergency department visits in comparison with the conventional care patients. Another advantage of real time access to patient data was reported by nurses in the improvement of clinical decision-making. The respondents indicated that they were very satisfied with the availability and comfort of remote monitoring. The research contributes to the idea of telehealth implementation into transitional and home nursing service as a successful method of enhancing the outcomes of post-operative recovery and maximizing the use of healthcare resources.
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Family-Centered Transitional Nursing Interventions for Stroke Survivors Returning Home
Vol.2(1); Pages:22-31. Published on May-2026
Abstract
The physical and mental challenges that the stroke survivors face when they are transferred to home settings after a period in the hospital rehabilitation units are often complex. This was a mixed-method research that determined the effectiveness of family-based transitional nursing interventions that aimed at improving recovery and caregiver preparedness. Three hundred and twenty stroke survivors receiving organized transitional assistance (home safety planning, caregiver education sessions, and nurse guided rehabilitation monitoring) were used to gather quantitative data. The scores of functional recovery and caregiver burden were evaluated in three months. Both patients and caregivers were interviewed qualitatively to investigate experiences of the transition process. Findings showed that functional independence scores and caregiver burden were lower than those in families who were provided with structured nursing guidance. The participants emphasized the importance of the individual approach to a care plan, the availability of nursing care communication, and emotional support in the early home adaptation process. Qualitative results also expressed that when nurses engaged family members actively in the planning and decision-making of rehabilitation, caregiver confidence was raised to a considerable extent. The paper focuses on the significance of family involvement in transitional nursing models addressing stroke treatment. The combination of caregiver-centered education and joint planning can enhance the long-term rehabilitation outcomes and enhance continuity between institutional and home-based care systems.
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Community Health Nurse Home Visits and Medication Safety in Recently Discharged Older Adults
Vol.2(1); Pages:32-40. Published on May-2026
Abstract
Medication errors frequently occur during the transition from hospital to home, particularly among older adults managing multiple prescriptions. This longitudinal observational study examined the impact of structured community health nurse home visits on medication safety and adherence following hospital discharge. A cohort of 178 elderly patients aged 70 years and older was monitored over a six-week period after discharge from acute medical wards. Community nurses conducted two scheduled home visits focusing on medication reconciliation, patient education, and assessment of potential drug-related complications. Data were collected on medication discrepancies, adherence levels, and patient understanding of prescribed therapies. Findings revealed that nearly one-third of participants initially exhibited medication discrepancies, including duplicate prescriptions and dosing misunderstandings. Following nurse-led interventions, medication adherence improved significantly and the number of discrepancies decreased substantially. Patients also reported increased confidence in managing complex medication schedules. The study underscores the essential role of home health nurses in identifying medication risks during care transitions. Structured nurse-led medication review programs may represent a critical strategy for enhancing patient safety and reducing preventable adverse drug events in home healthcare environments.
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Nurse-Led Transitional Palliative Care for Advanced Chronic Illness in Home Settings
Vol.2(1); Pages:41-49. Published on May-2026
Abstract
Patients who are chronically ill and have reached an advanced stage of the disease usually need a well organized process of moving out of hospital care and palliative services at home. The presented qualitative phenomenological research examined the experiences of patients and nurses in transitional palliative care in home environments. Palliative care programs at the community level were used to recruit 24 participants comprising of terminally ill patients and specialty home health nurses. Semi-structured in-depth interview was used to investigate the perceptions of continuity of care, managing symptoms, and providing emotional support during the process of transition between hospital discharge and home care. The thematic analysis was used to analyze the data and determine common patterns and insights. The results showed that good communication between the home health nurses and the hospital teams was a major factor of successful transitions. Respondents highlighted the need to plan early discharges, regular symptom monitoring, and psychosocial assistance by special nurses in the palliative care. When nurses were asked about individualized care planning and continuous preparation of caregivers, they said that these practices increased the comfort of patients as well as family preparedness. Patients indicated that they were grateful to get caring treatment in settings that were similar to their homes. The research indicates the importance of transitional palliative nursing in enhancing the quality of life of people living with advanced illnesses as well as supports them in the home based end-of-life care.
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