Research report: Process evaluation of a nurse-led transitional care model (Cardiolotse) within a randomized controlled trial aiming to improve care coordination for patients with cardiovascular diseases in Germany

A process evaluation of the German Cardiolotse randomized controlled trial found that participating cardiovascular patients viewed nurse-led transitional care positively and described their interactions with study nurses as trustworthy and reliable. Nurses made approximately 12,500 contacts during the intervention, providing post-discharge support intended to help patients navigate the healthcare system. Cardiolotse is designed for patients with cardiovascular disease who are being discharged from hospital, with particular attention to older patients, whom the study identifies as facing increased risk of readmission within 30 days.

The intervention’s study nurses, known as Cardiolotsen, contacted patients after discharge, checked their health status and adherence to therapy, and helped them navigate the healthcare system. The process evaluation examined how this support was delivered and which mechanisms were involved in producing change, rather than presenting the intervention as a demonstrated clinical treatment. Researchers followed the Medical Research Council framework for process evaluation and gathered evidence through semi-structured interviews with relevant target groups, questionnaires and medical records.

They analyzed the qualitative material using content analysis with both deductive and inductive categories, while descriptive statistics and subgroup analyses were used to explore the quantitative information. The study nurses responded positively to the designed training program. Patients receiving support from the Cardiolotsen also gave positive satisfaction ratings, and their reports of interacting with the nurses emphasized trust and reliability.

These findings document how the intervention was experienced by the nurses and patients included in the evaluation; they do not establish that Cardiolotse reduced readmissions or improved clinical outcomes. The evaluation was less conclusive about some aspects of coordination involving wider care teams. Researchers could not determine whether satisfaction scores concerning medical treatment or interactions among healthcare providers differed between the intervention and control groups.

At the same time, the quantitative and qualitative data suggested that Cardiolotse had difficulty reaching office-based physicians: regular contact between the study nurses and 90% of participating general practitioners and cardiologists could not be achieved. The authors therefore identified communication and information exchange across sectors between Cardiolotsen and office-based physicians as an implementation challenge. The results portray two different aspects of the program.

Its patient-facing support functions were recorded across the intervention: nurses checked patients’ health and therapy adherence at regular intervals, patients reported positive satisfaction, and the nurse-patient interactions were characterized as trustworthy and reliable. The model’s intended links with community-based physicians were less consistently established. Because this was a process evaluation embedded within the Cardiolotse randomized controlled trial, the reported findings concern implementation and participant experience rather than a direct comparison of clinical benefit.

The analysis was conducted in Germany within the trial registered retrospectively at the German Clinical Trial Register as DRKS00020424.

Subject of Research: Process evaluation of nurse-led transitional care for cardiovascular patients after hospital discharge in Germany

Article Title: Process evaluation of a nurse-led transitional care model (Cardiolotse) within a randomized controlled trial aiming to improve care coordination for patients with cardiovascular diseases in Germany

Article References: Kropp, S., Schüttig, W., Barzen Coors, M., Reber, K. C., Darius, H., Holzgreve, A., Karmann, S., Stürtz, A., Zöller, R., Riesner, P., & Sundmacher, L. (2026). Process evaluation of a nurse-led transitional care model (Cardiolotse) within a randomized controlled trial aiming to improve care coordination for patients with cardiovascular diseases in Germany. BMC Health Services Research, 26(1), Article 1254. https://doi.org/10.1186/s12913-026-15555-2

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DOI: 10.1186/s12913-026-15555-2

Keywords: Cardiolotse, transitional care, cardiovascular disease, nurse-led care, hospital discharge, process evaluation, care coordination, patient satisfaction, healthcare communication, randomized controlled trial, Process, evaluation