The Cardiac Care Bridge program is a nurse-coordinated transitional intervention that aims to reduce readmission and mortality in older cardiac patients (>70 years) at high risk of functional decline admitted to the departments of cardiology or cardiothoracic surgery. The intervention will be provided in three distinctive phases of care (clinical phase, transitional phase and post-clinical phase) and combines case management, disease management and home-based cardiac rehabilitation. In the clinical phase, patients in the intervention group will receive a comprehensive geriatric assessment and an integrated care plan based on identified problems by a cardiac nurse (disease manager). This plan is leading in all phases of care. In the transitional phase, a community-care registered nurse (case manager, CCRN) will receive a face-to-face handover of the integrated care plan by the disease manager. In addition, the CCRN will visit the patients to discuss and prepare discharge to home. In the post-clinical phase, the CCRN will visit the patient four times to establish and evaluate the integrated care plan. A primary care physiotherapist will perform home-based cardiac rehabilitation.
