Patients in the control group received usual care by the hospital. There was no contact between the patients in the control group and the study team throughout the 3 months interval. A scheduled telephone call was made at the end of 3 months when they were invited to participate in a telephone survey.

Intervention

A multidisciplinary team delivered the transitional care program.

Our transitional care program focused on four key areas:

1. Post discharge surveillance of the patient to ensure adherence to care plans.
2. Coordination of follow-up visits with specialist care providers.
3. Patent education and care giver training.
4. Activation of community and social services.

Upon recruitment, the patients were interviewed and assessed by the team nurse prior to their discharge. Intervention starts upon discharge from the hospital. The duration of the intervention program was 3 months. A follow-up by telephone was made within 72 hours after discharge to assess patient's condition and adherence to treatment plan. Home visits were made within 2 weeks after discharge.

Any hospital admission after randomisation