Hospital-to-home care is important for improving the quality of life (QOL) of patients with heart failure (HF). However, there is little evidence of outcomes regarding hospital-to-home care interventions in Japan. Thus, this integrative review aimed to identify the components and outcomes of hospital-to-home care interventions for patients with HF in Japan. Electronic databases, such as MEDLINE, CINAHL, and Ichushi-Web, were systematically searched, and all forms of hospital-to-home care interventions in Japan were examined. Studies regarding transitional care, discharge planning, home care, and disease management were included. The characteristics and results of the intervention studies were summarized. Furthermore, we analyzed the components of hospital-to-home care interventions and considered the effective interventions for patients with HF, based on statistically significant results. Ten articles including nine interventions were reviewed. The average age of intervention participants ranged from 64 to 77.5 years old, and the sample sizes in the intervention groups ranged from 11 to 192 participants. The intervention components were categorized as follows: "hospital-based components," "home- and outpatient-based components," and "both hospital- and home-based components." The main intervention components comprised structured education, lifetime counseling, and follow-ups via telephone and video calls. The clinical outcomes included readmission, mortality, and QOL, measured up to 24 months after the interventions. There was limited evidence of interventions being continued from the hospital to home, follow-up immediately after discharge, and nurse home visits in Japan. Further studies are necessary to evaluate the outcomes of patients' experiences immediately after discharge and the quality of care transition.

Background/Objectives: Older patients with cancer are predisposed to malnutrition, contributing to adverse postoperative outcomes, high complication rates, and poor prognosis, warranting dietary support from nurses. Practices and factors related to such support remain unexplored. We examined factors associated with discharge-oriented dietary support for older patients with cancer. Methods: This cross-sectional study involved registered nurses working in wards and was conducted using a self-report questionnaire between September 2024 and February 2025 at two regional core cancer Japanese hospitals. The survey included the Ward Nurses’ Discharge-Oriented Dietary Support Scale for Older Adult Patients (NDODSS), items assessing nurses’ perceived difficulty with cancer care, patient assessment, interprofessional collaboration, and their interest in, perceived importance of, and difficulty with dietary support. Data were analyzed using t-test, Pearson correlation, and multiple regression analysis. Results: Overall, 134 nurses, with an average of 6.8 years of cancer nursing experience, were included. The total mean scores for NDODSS, assessment of healthy eating behavior, adjustment of the living environment, and continual frailty assessment were 68.6 (11.8), 28.4 (4.9), 18.2 (4.7), and 22.0 (4.2), respectively. Multiple regression analysis showed that NDODSS was significantly associated with difficulty providing dietary support (β = −0.127, p = 0.043), physical assessment of cancer patients (β = 0.282, p < 0.001), social assessment (β = 0.207, p = 0.003), and consultation with other professionals (β = 0.205, p = 0.010). Conclusions: Dietary support for older patients with cancer requires a multidisciplinary approach, including cancer symptom assessment, social factor evaluation and sharing dietary support-related challenges.

Background: The Care Transitions Scale for Patients With Heart Failure (CTS-HF) is a scale that registered nurses working in the cardiovascular ward use to assess patients' readiness for hospital discharge; CTS-HF has shown sufficient reliability and validity for use. Objective: In this study, our aim was to test the relationship between assessments using CTS-HF by nurses and patients' difficulties of symptom management and self-care 1 week after discharge. Methods: In this longitudinal study we paired responses from nurses and patients with heart failure between 2022 and 2023. A nurse assessed a patient’s readiness for hospital discharge using CTS-HF. One week after discharge, patients with heart failure completed a questionnaire about their daily difficulties at home. The relationship between the nurse-reported CTS-HF scores and patients' difficulties at home was analyzed. Results: Twenty-three dyads of nurse-patient responses were included in the analysis. Nurse-assessed CTS-HF scores were significantly correlated with patients' symptom management difficulties at home ( r = −0.471, P = .012), degree of interference with daily life due to symptoms ( r = −0.530, P = .005), daily healthy ways to manage symptoms ( r = 0.561, P = .003), and emotional support at home ( r = 0.435, P = .019). Conclusions: Nurse-reported CTS-HF scores showed a relationship with patients' difficulties after discharge. Because nurses' assessment before discharge may predict patients' difficulties managing symptoms after discharge, such discharge readiness assessment by nurses using CTS-HF may be useful in transitional care from hospital to home. Further studies on patients with complex care needs are warranted.