The process evaluation of the Cardiolotse nurse-led transitional care model found that while the intervention was positively received by patients and study nurses, cross-sectoral communication and information exchange between care navigators (Cardiolotsen) and office-based physicians was identified as a key implementation challenge.
The training programme for study nurses (Cardiolotsen) was perceived positively by the nurses themselves.
Patients receiving support from Cardiolotsen reported positive satisfaction ratings and described interactions as trustworthy and reliable.
Approximately 12,500 total contacts were made between Cardiolotsen and patients over the course of the intervention.
No statistically detectable changes in satisfaction scores between intervention and control groups could be determined for medical treatment or provider interactions.
There were significant reach issues with office-based physicians, with regular Cardiolotse contact not achieved with 90% of participating general practitioners and cardiologists.
The study followed the Medical Research Council (MRC) Framework for process evaluation, using mixed methods including semi-structured interviews, questionnaires, and medical records.
The target population of the Cardiolotse intervention was older patients with cardiovascular disease who are at higher risk of readmission within 30 days after hospital discharge.
This research evaluated a German nurse-led care program called 'Cardiolotse,' designed to support older heart disease patients after they leave the hospital. The program used specially trained nurses ('Cardiolotsen,' meaning care navigators) to check in regularly with patients, monitor their health, and help them navigate the healthcare system — with the goal of reducing the risk of being readmitted to the hospital within 30 days of discharge. The evaluation looked at how well the program was implemented, not just whether it worked, following a structured framework for understanding complex health interventions. The study found that patients generally appreciated the support from their care navigators, describing interactions as trustworthy and reliable, and the nurses themselves responded positively to their training. Over the course of the study, about 12,500 contacts were made between nurses and patients. However, the program struggled significantly to connect with family doctors and cardiologists working in outpatient settings — regular contact could not be established with 90% of the participating office-based physicians. This meant the coordination between hospital-based care navigators and community-based doctors was largely not achieved, which is a critical gap in a program designed to bridge hospital and community care. No measurable improvement in patient satisfaction with medical care or provider communication was detected between the groups receiving the intervention and those who did not. This research suggests that while the patient-facing components of transitional care programs can be successfully implemented and well-received, integrating such programs with existing outpatient physician networks remains a major practical challenge. Future programs of this type may need to develop specific strategies to engage office-based physicians more effectively, as their participation appears essential for achieving true care coordination across healthcare settings.
Kropp S, Schüttig W, Barzen Coors M, Reber K, Darius H, Holzgreve A, et al.. (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. https://doi.org/10.1186/s12913-026-15555-2