Community-Based Nursing Interventions, Discharge Planning and Hospital Readmissions in Nyandeni Local Municipality, Eastern Cape, South Africa

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Background Chronic diseases place a substantial pressure on healthcare systems, particularly in resource-constrained rural settings. Community-based nursing interventions and effective discharge planning are recognised as key strategies for improving continuity of care and reducing avoidable hospital readmissions. The aim of this study was to explore community-based nursing interventions, discharge planning, continuity of care, and hospital readmissions among patients with chronic diseases in Nyandeni Local Municipality, Eastern Cape, South Africa. Methods An exploratory descriptive design was employed. Data were collected through semi-structured interviews of patients with chronic diseases, a focus group discussion with nurses involved in community-based care, and a retrospective review of patient records using a structured Patient Record Summary Analysis Checklist. Qualitative data were analysed using Braun and Clarke's thematic analysis, while document review data were analysed descriptively. Findings from the three data sources were integrated through methodological triangulation. Results Four integrated themes emerged: (1) community-based nursing interventions promote continuity of care and chronic disease management; (2) discharge planning and care coordination support continuity of care; (3) health system and socioeconomic barriers limit effective community nursing; and (4) collaborative partnerships facilitate successful community-based care. Community-based nursing interventions improved treatment adherence and continuity of care. However, inadequate discharge documentation, weak community referrals, and rural health system challenges limited their effectiveness, while family support and multidisciplinary collaboration enhanced patient care. Conclusion Community-based nursing interventions are fundamental to strengthening continuity of care for patients with chronic diseases in rural communities. Their effectiveness, however, depends on comprehensive discharge planning, coordinated referral systems, multidisciplinary collaboration, and strengthened rural health systems. Addressing documentation gaps, improving post-discharge care coordination, and investing in community-based primary healthcare services may reduce avoidable hospital readmissions and improve long-term outcomes for chronic diseases in resource-limited settings.

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