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This quantitative phase of a mixed-methods study aims to describe the effect of the Transitional Care Bridge (TCB) programme on functional decline, mortality, health-care utilisation and health outcomes compared to usual care in a regional hospital in the Netherlands.

In a pre- and post-cohort study, patients aged ≥70 years, admitted to the hospital for ≥48 h and discharged home with an Identification of Seniors at Risk score of ≥2, were included. The TCB programme, started before discharge, encompassed six visits by the community nurse (CN). Data were obtained from the hospital registry and by three questionnaires over a three months period, addressing activities of daily living (ADL), self-rated health, self-rated quality of life and health-care utilisation.

In total, 100 patients were enrolled in this study, 50 patients in the TCB group and 50 patients in the usual care group. After three months, 36.7% was dependent on ADL in the TCB group compared to 47.1% in the usual care group. Mean number of visits by the CN in the TCB group was 3.8. Although the TCB group had a lower mortality, this study did not find any statistically significant differences in health outcomes and health-care utilisation.

Challenges in the delivery of the programme may have influenced patient outcomes. More research is needed on implementation of evidence-based programmes in smaller research settings. A qualitative phase of the study needs to address these outcomes and explore the perspectives of health professionals and patients on the delivery of the programme.

This study provides valuable information on the transitional care programme in a smaller setting.