The control group received routine care.

The intervention group received a transitional care intervention mainly focused on the transitional care model (TCM).

The intervention group received a transitional care intervention mainly focused on the transitional care model (TCM).

The measurement tool adopts the Chronic Disease Self-Efficacy Questionnaire compiled by Stanford University in the United States.The scoring consists of two dimensions: symptom management and disease-commonality management. The self-efficacy score for symptom management is calculated by averaging items 1, 2, 3, and 4 (if two or more items are missing or omitted, the variable is considered missing). A higher score indicates greater self-efficacy in symptom management. The self-efficacy score for disease-commonality management is obtained by averaging items 5 and 6. The score ranges from 1 to 5, a higher score indicates higher self-efficacy in disease-commonality management.

In this study, the Chinese version of the self-care ability scale for elderly, translated by Guo , was used. The scale demonstrates good reliability and validity, with a Cronbach's α coefficient of 0.82, a test-retest reliability of 0.82, and a content validity index of 0.94. The scale consists of 17 items and is applicable to all older adults. Scoring on the scale ranges from "completely disagree" to "completely agree," with scores ranging from 1 to 5. Higher scores indicate a higher self-care ability in older adults.

The study mainly measures the re-hospitalisation of the study subjects and whether the re-hospitalisation rate of the two groups has changed. By counting the re-admission of the study subjects, the re-admission rate of the two groups is calculated, which is mainly collected through the combination of the hospital's HIS system inquiry and asking patients or family members. HIS's scoring adopts the method of multi-dimensional evaluation. Each dimension contains multiple items, and each item has a corresponding scoring standard. The scoring generally adopts the five-level method, from 0 to 4 points, indicating no impact, mild impact, moderate impact, severe impact and very serious impact respectively.