Effect of a tailored Cardiac-Diabetes Trans-Care program compared to usual care on hospital readmission rates and health-related quality of life in patients with dual diagnoses of acute coronary syndrome and type 2 diabetes

The "Cardiac/Diabetes TRANS-CARE program", which consists of two face-to-face sessions, a home visit and telephone follow-up. Purpose of the intervention: to increase self-efficacy to enhance self-management behaviours and thus improve health outcomes and reduce hospital readmissions. Contents/Duration (Reference: Wu & Chang 2014 http://onlinelibrary.wiley.com/doi/10.1111/inr.12104/pdf ): - 2 sessions (2 x 30 minute sessions, separated by 1 day) while in hospital: these sessions will be provided by a trained research nurse, and focusing on 1) assessing patient’s knowledge of their conditions and skills and confidence in self-management; 2) providing patient examples or models of someone in a similar situation. - 1 in-home visit with duration of approx 1 hour: The home visit will be provided by a trained research nurse within the first week post discharge. This visit is to ensure that patients will be sufficient support, information, self-management activities including their treatment regimens are carried out in home environment, reinforcement and further explanation of self-management program - weekly telephone calls for 4 weeks after home visit, and monthly up to 6 months. These calls will be undertaken by the trained research nurse. The telephone follow up calls are to ensure that patients have sufficient support, to encourage and reinforce the participant to continue practising the knowledge and skills to self-manage their conditions. Each phone call will take 20-30 minutes.