60% of patients who meet the inclusion criteria consent to participate in the study
61% consented (8/13)
50% of patients assign an informal caregiver
62.5% assigned informal caregiver
90% completes baseline demographics and questionnaires by participants at baseline
100% complete questionnaires at baseline
80% completed primary outcome (readmission) 80% complete questionnaires by alive participants at the follow-up measure points (2 weeks and 1, 3 and 6 months post-discharge)
75% completed questionnaires, primary outcomes known for all
Burden for patients and informal caregivers to complete the questionnaires is low, median score lower than 4 on a 10 point Likert scale
Patients scored the burden of answering the questionnaires as low with a median score of 1.6 (IQR 1–3) on a 10-point Likert scale.
Patients complete all the steps of the intervention (specified in Table 1) or meet the primary endpoint (death)
Not all steps of the interventions were followed for all patients
