Nurse-Led Remote Transitional Care for Chronic Internal Medicine Conditions: A Narrative Review of Models, Outcomes, and Implementation Priorities

Abstract

Chronic internal medicine conditions, including diabetes mellitus, chronic heart failure, hypertension, and chronic obstructive pulmonary disease, require sustained self-management after hospital discharge and between clinic visits. Conventional hospital-centered nursing models are often insufficient for long-term symptom monitoring, medication adherence, lifestyle modification, and timely escalation of care. Nurse-led remote transitional care combines telehealth, telenursing, mobile health, remote patient monitoring, structured education, and behavioral coaching to extend nursing support into home and community settings. Recent systematic reviews and meta-analyses suggest that nurse-led digital interventions can improve self-management capacity, glycemic control, blood pressure, health-related quality of life, symptom burden, and selected health-service outcomes. However, the field remains heterogeneous in intervention content, intensity, theoretical basis, technology platform, and outcome measurement. This narrative review summarizes current evidence on nurse-led remote transitional care for major chronic internal medicine conditions, analyzes core mechanisms and implementation barriers, and proposes future directions for precision, equity-oriented, and data-enabled chronic disease nursing.