A Prospective Randomised Control Trial to Study the Effectiveness of a Health Service Innovation Using a Modified Virtual Ward Model to Prevent Unscheduled Readmission of High Risk Patients

"A multidisciplinary team delivered the transitional care program.~Our transitional care program focused on four key areas:~1. Post discharge surveillance of the patient to ensure adherence to care plans.~2. Coordination of follow-up visits with specialist care providers.~3. Patent education and care giver training.~4. Activation of community and social services.~Upon recruitment, the patients were interviewed and assessed by the team nurse prior to their discharge. Intervention starts upon discharge from the hospital. The duration of the intervention program was 3 months. A follow-up by telephone was made within 72 hours after discharge to assess patient's condition and adherence to treatment plan. Home visits were made within 2 weeks after discharge."