Table 1

Main characteristic of the APN-led models of care included in this review

StudySource origin, country of originAims, purpose of the studyStudy designHospital settingSample sizeAge (mean years)Concept (duration)
Core group (leadership)
Title of APN
Allen et al59American Heart Journal
USA

  • Effectiveness of a nurse case management programme of individualised lifestyle modification and pharmacological intervention to lower blood lipids in patients with CHD

  • Compared with usual care

  • 1 year after discharge

  • Patients with hypercholesterolaemia with CHD

Randomised controlled trialTertiary medical centre228
NURS=115
EUC=113		Adults
NURS
(61.1±10.3)
EUC
(59.6±9.6)		Nurse case management (12 months)
NURS group:
Partnership of NP, primary provider and/or cardiologist
EUC group:
Primary provider and/or cardiologist
NP
Hirschman and Bixby60Diabetes Spectrum
USA

  • Transitional care management process of an APN

  • 2 months after discharge

  • Patient with diabetes, hypertension, high cholesterol and gastro-oesophageal reflux disease

Descriptive case studyHospital to home162 yearsTransitional care model (2 months)
APN:
Hospital-based care team and diabetes educator, unit-based clinical nurse specialist and staff nurses
Primary care:
Primary care providers
APN
Li et al61Canadian Journal of Diabetes
Canada

  • Impact of DNP intervention on glycaemic control, quality of life and diabetes treatment satisfaction in patients with type 2 diabetes admitted to cardiology inpatient services

  • 3 months and 12 months after discharge

  • Patients with diabetes mellitus admitted to cardiology inpatient services

Preinterventional and postinterventional studyUniversity of Alberta23(62.6 years)Care management (12 months)
DNP
DNP
Litaker et al62Journal of Interprofessional Care
USA

  • Compare selected outcomes for a new chronic disease management programme involving an NP - physician team with those of an existing model of care

  • Compared with usual care

  • 12 months, 18 months and 24 months after discharge

  • Patients with hypertension and non-insulin-dependent diabetes mellitus

Randomised controlled trialGeneral Internal Medicine at the Cleveland Clinic157
NP-MD=79
MD only=78		NP-MD team
(60.5 years)
MD only (60.6 years)		Chronic disease management programme (12 months)
NP-MD
NP
Zimmerman et al63Western Journal of Nursing Research
USA

  • Cost-effectiveness of four different doses of a home-based care transitions intervention

  • Compared with usual care

  • 2 and 6 months after hospital discharge to home

  • Three or more chronic diseases

Randomised controlled four groups/eight arms repeated-measures designUniversity Hospital222
Group 1 (LC/LA): n=62
Group 2 (LC/HA): n=90
Group 3 (NC/LA): n=39
Group 4 (NC/HA): n=72		19 years and older
(61 years)		Care transition intervention (6 months)
Home-based care transition interventions versus usual care
Group 1 (LC/LA): APRN-NP and CNA team for 8 weeks
Group 2 (LC/HA): APRN-NP and CNA team for 8 weeks
Group 3 (NC/LA): RN coach intervention for 4 weeks
Group 4 (NC/HA): one follow-up visit at home or by phone by RN coach; APRN-NP

  • APN, advanced practice nurse; APRN-NP, advanced practice registered nurse–nurse practitioner; CHD, coronary heart disease; CNA, certified nursing assistant; DNP, diabetes nurse practitioner; EUC, Primary providers and/or cardiologist; HA, high activation; LA, low activation; LC, low cognition; MD, physician; NC, normal cognition; NP, nurse practitioner; NP-MD, nurse practitioner-physician team; NURS, Nurse Practitioner, primary providers and/or cardiologist; RN, registered nurse.