Impact of a structured, nurse-led transitional care model on self-efficacy and unplanned readmissions in patients receiving sequential CAR-T therapy for lymphoma.

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Background: Sequential CAR-T therapy for relapsed/refractory lymphoma imposes severe physiological and psychological burdens, exacerbated by a fragmented care continuum. Standard nursing care prioritizes acute inpatient toxicity, creating gaps in post-discharge patient empowerment. We evaluated a structured, nurse-led transitional care model (TCM) designed to enhance self-efficacy, alleviate distress, and ensure continuous care from the inpatient setting to the home. Methods: A prospective observational study (March 2024–November 2025) enrolled 27 lymphoma patients receiving a second or subsequent CAR-T infusion. The TCM featured four pillars: 1) Pre-infusion empowerment focusing on symptom self-monitoring; 2) Inpatient symptom cluster surveillance (tracking fatigue, low-grade fever, cognitive fog) for early CRS/ICANS detection; 3) Guided discharge utilizing teach-back validation; and 4) 90-day post-discharge digital health navigation via telehealth. Primary endpoints were baseline to Day +90 changes in self-efficacy (General Self-Efficacy Scale) and psychological distress (HADS). The secondary endpoint was the 30-day unplanned readmission rate. Results: The TCM was successfully implemented in all 27 patients. Mean GSES scores improved significantly from 25.4 at baseline to 33.1 at Day +90 (p<0.001). Psychological burden was notably reduced: mean HADS-Anxiety decreased from 9.8 to 6.2 (p<0.01), and HADS-Depression from 8.5 to 5.9 (p<0.05). The 30-day unplanned readmission rate for toxicity/infection was 7.4% (n=2), a profound reduction compared to the 25% institutional historical control (p<0.05). Early symptom surveillance triggered preemptive clinical interventions in 55.6% of cases (n=15), effectively preventing any progression to grade ≥3 ICANS. Conclusions: A structured, nurse-led TCM significantly improves patient self-efficacy, alleviates psychological distress, and reduces costly unplanned readmissions in sequential CAR-T therapy. By shifting clinical focus from reactive acute management to proactive patient navigation, this model provides a highly scalable, evidence-based framework to optimize holistic outcomes in vulnerable oncology populations.