Table 1.

Transitional care plan

Category	Time	Implementation method
Structural assessments and corresponding interventions designed on the basis of the Omaha System	1, 4, 8, and 12 weeks after discharge	Face-to-face contact with the participants. A client-centered approach was used to address patients’ existing or potential health problems. First, identify patients’ existing or potential health problems: 23 systemic lupus erythematosus–related health problems were scored on knowledge, behavior, and status of disease management by using the three Likert 5-point scales. Second, provide corresponding interventions: If any one of the scores of a patient’s knowledge, behavior, or status is less than 4 points, the intervention categories and specific interventions corresponding to the problem would be provided.
Telephone follow-up	2, 3, 6, and 10 weeks after discharge	Phone counseling was conducted to identify and discuss any barriers and concerns which the patient may have regarding their disease.