Optimizing the care transition process enhances outcomes, reduces readmission rates, and increases patient satisfaction. Our project addresses the need for improved knowledge levels, self-care behaviors, and structured discharge plans for recently transplanted renal patients, aiming to mitigate the risk of rehospitalization within the first 30 days post-discharge. The study's objective is to design and implement a patient-centered care transition project focusing on renal patients recently transplanted from hospital to home. Centered on coordinated actions and shared best practices among care stakeholders, the project integrates three sub-studies: an integrative literature review, translation and cultural adaptation of six instruments to European Portuguese, and a pilot study. Adopting a before-and-after design with a non-equivalent control group, the study employs the BOOST model for optimizing safe transitions, aligning with patient-centered care principles. The Practice-Based Evidence implementation project aims to create, implement, and evaluate a transition care program, featuring structured and individualized education interventions and discharge plans with one-year follow-up for recently transplanted renal patients. Utilizing instruments such as the Kidney Knowledge Understanding Tool (KTUT), Readiness for Hospital Discharge Scale (RHDS) short version, patient and nurse perceptions, Kidney Transplant Self-Management Scale, Care Transitions Measure, and Chronic Kidney Disease Terminal Module - Renal Transplant, we present preliminary results from the pilot study. The sample includes 12 participants in the experimental group (GE) and 11 in the control group (GC). Initial findings show that 99% of participants possess general knowledge about renal transplantation. Regarding immunosuppressive medication, both groups improved knowledge over subsequent assessments, with the GE consistently outperforming the GC. In terms of discharge preparedness, the GE demonstrated higher perception levels than the GC (84.8% versus 71.4%). These results suggest that an education program contributes to increased knowledge about renal disease and facilitates a smoother transition from hospital to home. This ongoing project underscores the importance of patient-centered care in optimizing care transitions for recently transplanted patients.

Dilar Costa earned her Ph.D. in Nursing in 2014 and has been the Nurse Manager in the Nephrology and Kidney Transplantation department since 2013. She is a prolific author of articles and book chapters, contributing significantly to the field. Dr. Costa is also a respected reviewer for various international journals, showcasing her commitment to advancing nursing knowledge in nephrology.