OBJECTIVE To evaluate the effectiveness of a nurse-led hospital-to-home transitional care intervention versus usual care on mental functioning (primary outcome), physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use costs in older adults with multimorbidity (≥ 2 comorbidities) and depressive symptoms. DESIGN AND SETTING Pragmatic multi-site randomized controlled trial conducted in three communities in Ontario, Canada. Participants were allocated into two groups of intervention and usual care (control). PARTICIPANTS 127 older adults (≥ 65 years) discharged from hospital to the community with multimorbidity and depressive symptoms. INTERVENTION This evidence-based, patient-centred intervention consisted of individually tailored care delivery by a Registered Nurse comprising in-home visits, telephone follow-up and system navigation support over 6-months. OUTCOME MEASURES The primary outcome was the change in mental functioning, from baseline to 6-months. Secondary outcomes were the change in physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use cost, from baseline to 6-months. Intention-to-treat analysis was performed using ANCOVA modeling. RESULTS Of 127 enrolled participants (63-intervention, 64-control), 85% had six or more chronic conditions. 28 participants were lost to follow-up, leaving 99 (47 -intervention, 52-control) participants for the complete case analysis. No significant group differences were seen for the baseline to six-month change in mental functioning or other secondary outcomes. Older adults in the intervention group reported receiving more information about health and social services (p = 0.03) compared with the usual care group. CONCLUSIONS Although no significant group differences were seen for the primary or secondary outcomes, the intervention resulted in improvements in one aspect of patient experience (information about health and social services). The study sample fell below the target sample (enrolled 127, targeted 216), which can account for the non-significant findings. Further research on the impact of the intervention and factors that contribute to the results is recommended. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT03157999.

中文翻译：

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护士主导的医院到家庭过渡护理干预对患有多种疾病和抑郁症状的老年人的有效性：一项务实的随机对照试验。

目的 评估护士主导的医院到家庭过渡护理干预与常规护理对心理功能（主要结果）、身体功能、抑郁症状、焦虑、感知社会支持、患者体验和医疗服务使用成本的有效性。患有多种疾病（≥ 2 种合并症）和抑郁症状的老年人。设计和设置 在加拿大安大略省的三个社区进行的务实的多中心随机对照试验。参与者被分为干预组和常规护理组（对照组）。参与者 127 名老年人（≥ 65 岁）出院到社区，患有多种疾病和抑郁症状。干预 这种基于证据的，以患者为中心的干预包括由注册护士提供的个性化护理服务，包括 6 个月内的家访、电话随访和系统导航支持。结果测量 主要结果是心理功能的变化，从基线到 6 个月。次要结果是身体机能、抑郁症状、焦虑、感知社会支持、患者体验和医疗服务使用成本的变化，从基线到 6 个月。意向治疗分析使用 ANCOVA 模型进行。结果 在纳入的 127 名参与者（63 名干预组，64 名对照组）中，85% 的人患有 6 种或更多慢性病。28 名参与者失访，剩下 99 名（47 名干预，52 名对照）参与者进行完整的病例分析。心理功能或其他次要结果的基线至 6 个月变化未见显着组间差异。与常规护理组相比，干预组的老年人报告获得了更多有关健康和社会服务的信息 (p = 0.03)。结论 尽管在主要或次要结果方面没有发现显着的组间差异，但干预导致患者体验的一个方面（有关健康和社会服务的信息）有所改善。研究样本低于目标样本（入组 127 个，目标 216 个），这可以解释不显着的结果。建议进一步研究干预的影响和促成结果的因素。试验注册clinicaltrials.gov 标识符：NCT03157999。