To evaluate the effectiveness of Nurse Led Transitional Care Model (TCM) on the functional autonomy, quality of life and rehospitalization rates of elderly patients undergoing open heart surgery.

Rate and number of successful cases in open heart surgery has been increasing due to the advances in medical technology and surgery. To improve patient convalescence results and reduce rate of post-discharge readmission to hospital and unplanned post-discharge rehospitalization, home-care and follow-up process of patients should be managed successfully.

A total of 66 elderly patients who agreed to participate in the study between November 2017 and December 2018 were randomly assigned to the intervention (n: 33) and control (n: 33) groups. Patients in intervention group were given care based on the TCM until the post discharge 9th week starting from date of hospitalization. Patients in control group were given standard care services. Functional autonomy and quality of life levels of patients were evaluated at admission to the clinic and at the post-discharge 9th week whereas their repeated admission rates to the clinic and re-hospitalization rates were evaluated at post discharge 2nd, 6th and 9th weeks and finally 6 months. The CONSORT checklist was used to check the procedure.

Inclusion Criteria:

• be hospitalized for the first time and for elective open heart surgery;
• have no other surgical intervention other than an open heart surgery,
• have no psychological and mental disorders,
• have no major chronic problems such as kidney problems, neurological problems or cancer,
• be able to speak Turkish,
• be available to be communicated by phone,
• provide consent to participate in the study,
• live at a maximum distance of 50 km from the hospital (for easy access during post-discharge follow-up visits).

Exclusion Criteria:

• ask to leave the study,
• be exposed to a disease or trauma that may affect his/her functional autonomy during the study,
• die throughout the study