Understanding Nurse-Led Care Transitions and Their Effectiveness in Reducing Preventable Rehospitalisations Across the Life Span in South West Nigeria

Background: Care transitions between hospital and community settings represent high-risk periods for preventable rehospitalisations. Nurse-led transition interventions have demonstrated efficacy in international settings, but contextual effectiveness data from South West Nigeria are absent. Aim: This study investigated the effectiveness of nurse-led care transition interventions on preventable rehospitalisation rates across adult and elderly populations in South West Nigeria. Methods: A multi-site pragmatic randomised controlled trial enrolled 380 patients across four hospitals in Ogun, Ondo, and Ekiti States. Intervention nurses delivered structured discharge coaching, follow-up telephone calls, and community linkage. The primary outcome was 30-day unplanned rehospitalisation. Secondary outcomes included medication adherence, primary care follow-up rates, and quality of life. Intention-to-treat analysis used logistic regression. Results: The intervention group had significantly lower 30-day rehospitalisation rates (14.3% vs 26.8%, OR = 0.46, p < 0.001). Medication adherence and primary care attendance were significantly higher in the intervention arm. Elderly patients aged over 65 showed the largest benefit. Conclusion: Nurse-led care transition interventions are effective and contextually feasible in South West Nigeria. System-level scale-up requires nurse transition coach training, standardised transition protocols, and hospital-community information sharing platforms. Keywords: care transitions, nurse-led interventions, rehospitalisation, South West Nigeria, hospital-community.