American Journal of Advanced Multidisciplinary Innovation and Research

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Nurse-Led Digital Navigation for Postdischarge Continuity

Author(s) Antonio Bonacaro
Country United States
Abstract The transition from hospital to home is a clinically vulnerable period during which patients must interpret discharge instructions, reconcile medications, recognize changing symptoms, arrange follow-up appointments, and coordinate multiple services with substantially less professional supervision than was available during hospitalization. Nurse-led transitional-care models have demonstrated the importance of continuity across settings, while telephone follow-up research indicates that postdischarge nursing contact can address information and communication needs, although effects on hospital readmission have varied among studies. The present study develops a simulation-based model of nurse-led digital navigation that combines telephone contact, secure messaging, digital reminders, symptom check-ins, medication clarification, follow-up coordination, and nurse-directed escalation. A hypothetical cohort of 500 adults discharged from acute hospital care was divided equally between a digitally supported nurse-navigation pathway and conventional discharge follow-up. Because no original clinical dataset was provided, all numerical outcomes are synthetic and intended for methodological demonstration.
The simulated pathway produced higher rates of successful contact within 48 hours, medication-issue resolution, scheduled follow-up completion, appropriate escalation of concerning symptoms, and overall 30-day continuity. Among digitally navigated participants, 84% were modeled as maintaining continuity through the first 30 days compared with 61% under conventional follow-up. Medication questions or discrepancies accounted for 31% of simulated problems detected through navigation, followed by new or worsening symptoms at 25%. The findings support conceptualizing digital navigation not as an automated substitute for clinical care but as a nurse-mediated continuity infrastructure through which digital tools organize information, identify gaps, and connect patients with appropriate professional services. Future empirical evaluation should examine patient safety, equity, nursing workload, digital accessibility, unresolved medication discrepancies, follow-up completion, and health-service utilization rather than relying on readmission alone.
Keywords nurse-led care; digital navigation; postdischarge continuity; transitional care; telephone follow-up; care coordination; nursing informatics; medication reconciliation; patient safety; hospital discharge
Field Engineering
Published In Volume 4, Issue 5, September-October 2023
Published On 2023-10-03
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