Table 1.

Summary of 15 patient-centered multi-component nursing interventions protocols at home

Clinical assessment after hospitalization	Nurse-led intervention	Protocol	Usual home care protocol
Delirium risk factor rate	Assessment of delirium risk factors among the discharged older patient.	Applying the clinical assessment checklist	None
Cognitive impairment and/or disorientation after hospitalization	Provide lighting, signs, calendars and clocks. Reorientation of the individual to time, place and person. Introduce cognitively stimulating activities such as reminiscence, preferred music or storytelling.	Orientation and cognitive therapeutic activities	None
ADL/IADL performance and needs of assistance at home	Encourage accepting aid and assistance for the ADL/IADL activities with the aim to find independency for daily activities of living as quickly as possible. Balance between autonomy/privacy and assistance.	ADL/IADL assistance	None
Dehydration	Encourage to drink at least 1.5 l parenteral fluids. Use mouth dehydration assessment to assess dehydration.	Hydration	None
Post-discharge constipation	Encourage fluid intake, fiber-enriched alimentation and mobility, especially among post-surgery opioid-treated older adults to restore daily toilet visit.	Anticonstipation after hospitalization	None
Hypoxia	Assess for hypoxia with portable saturation device. Encourage regular physical activities to enhance pulmonary capacities.	Hypoxia protocol based on EBP in hypoxia in the home care setting	None
Post-discharge immobility or limited mobility	Encourage mobility and outside walks. Use walking aids to prevent falls. Develop a daily and weekly mobility program in collaboration with informal caregivers and physiotherapist.	Mobilization protocol	None
Infection prevention	Regular assessment for pulmonary, urine tract, skin and other infections. Implement health education and promotion to prevent/detect infections.	Monitoring of infections Use assessment/prevention of skin, urinary tract and pulmonary infections	None
Polymedication, over-the-counter medications and alcohol abuse	Review medication for type and number of medications. Health education and promotion of the danger of auto-medication, over-the-counter medication, psychoactive medication, analgesia and alcohol use.	Psychoactive medication and healthy aging protocol	None
Post-discharge pain	Assess for pain at each home visit, inform informal caregivers of the importance to treat pain.	Pain management protocol	None
Nutrition at home	Encourage to consume equilibrated meals 3 times a day. Propose in collaboration with the informal caregivers’ assistance to prepare meals or to use the home-meal delivery service. Encourage regularly dentist visits.	Equilibrated feeding protocol	None
Sensory impairment	Resolve reversible cause of the sensory impairment. Ensure that hearing and visual aids are available, working and used by those who need them.	Vision protocol Hearing protocol	None
Sleep disturbance	Avoid nursing procedures and medication schedule during sleep. Reduce the number of visits late at evenings and avoid noise during the night.	Sleep enhancement protocol	None
Securing living environment at home	Assessment of fall risk by an occupational therapist. Eliminate all potential risks to fall such as carpets and steps. Equip the bathroom with aids to facilitate toilet use, bathing and showering	Security and fall prevention protocol at home	None
Reinforcing social network	Prevent loneliness and social isolation. Encourage communication, social network propositions and visits of close friends without overstimulating.	Social network protocol	None