Table 1 Transitional care plan

Structural assessments and corresponding interventions designed on the basis of the Omaha System

1, 4, 8, and 12 weeks after discharge

Face-to-face contact with the participants. A client-centered approach was used to address patients’ existing or potential health problems.

First, identify patients’ existing or potential health problems: 23 systemic lupus erythematosus–related health problems were scored on knowledge, behavior, and status of disease management by using the three Likert 5-point scales.

Second, provide corresponding interventions: If any one of the scores of a patient’s knowledge, behavior, or status is less than 4 points, the intervention categories and specific interventions corresponding to the problem would be provided.

Telephone follow-up

2, 3, 6, and 10 weeks after discharge

Phone counseling was conducted to identify and discuss any barriers and concerns which the patient may have regarding their disease.