Table 1.

Outline and the content of the personalized care planning intervention.

Stage	Objectives	Main tasks performed by nurses	Patients’ adaptive tasks
Pre-discharge
Preparation for discharge	Assessing patients’ health status and making tailored recommendations	·Reviewing patients’ history of treatment ·Assessing patients’ self-care behaviors ·Discussing patients’ experiences of HF control ·Setting personal goals ·Developing a personalized RHPT;	·Acquiring information ·Mitigating fluid overload ·Reviewing the RHPT
Post-discharge
Ten telephone calls	Facilitating patients’ adaption to HF: knowledge acquisition, skill training, behavior changing and reflecting	·Evaluating patients’ completion of prior planning ·Assessing individuals’ performance of self-care of HF ·Answering patients’ questions ·Discussing cultural-tailored self-care knowledge ·Discussing cost-effective care planning and refining the RHPT (dietary management, medication adherence, self-monitoring of fluid, exercise, prevention and early detection of complications) ·Encouraging patients to build supportive relationships with family and friends;	·Reflecting self-care experience and goal achievements during this period ·Setting goals, planning, prioritizing, and pacing ·Monitoring and managing HF symptoms and body responses ·Using available resources (personal, community, and social) effectively ·Seeking support of family and friends ·Changing behaviors to minimize HF impact ·Taking actions to prevent complications
Weekly internet-based consultation	Reinforcing the interventions and creating a supportive environment by organizing WeChat forums	·Encouraging patients to share experiences with peers in WeChat forums ·Solving the common problems reflected by patients ·Discussing self-care knowledge	·Processing and sharing emotions ·Seeking resources from specialists and peers ·Obtaining and managing social support ·Recognizing limits ·Managing symptoms and side effects
Tracing patients’ outcomes	Building a close relationship between nurses and patients	·Monitoring patients’ self-care progress ·Preparing the motivational interviewing	·Keeping engaged in the self-care of HF ·Reporting health-related indexes
Clinic follow-ups (optional)	Regular follow-up and providing the support of health care professionals	·Navigating the health care profile ·Summarizing patients’ needs and reporting them to physicians effectively	·Keeping appointments ·Performing treatments ·Using resources effectively

Note: HF = heart failure. RHPT = Return to Home Planning Template.