Table 5 Evaluation of the effectiveness of traditional care in kidney transplant recipients

1. Physiological Domains

1.1. Transplanted kidney function

1.2. Infection status

1.3. Cardiovascular function

1.4. Digestive function

1.1.1. Creatinine

1.1.2. Be aware of the signs of rejection and inform the health care provider in a timely manner

1.2.1. History of post-discharge infections requiring in-patient treatment (lung infections, urinary tract infections, etc.)

1.2.2. To know the symptoms of infection and seek medical attention soon

1.2.3. To know the precautions for lung infection and urinary tract infection

1.3.1. Blood pressure

1.3.2. Be aware of the importance of managing blood pressure and lipids and the normal values of the indicators

1.3.3. Overall cholesterol level

1.4.1. Diarrhea occurred after discharge from the hospital

1.4.2. To know the simple management of diarrhea and nausea/vomiting

1.4.3. Nausea/vomiting after discharging from hospital

2. Psychological Domains

2.1. Positive mental state

2.2. Negative mental state

2.1.1. I am fully confident about my future life

2.1.2. I can tolerate and maintain a good attitude in the face of possible post-transplant problems (elevated creatinine, lung infections, etc.)

2.1.3. Do you have a positive attitude about your current physical condition

2.2.1. Anxiety/depression (due to appearance, body shape changes, complications, secondary transplants, costs, etc.)

2.2.2. Be well-informed about solutions for anxiety alleviation

3. Health Behaviour-related Domains

3.1. Medication adherence

3.2. Regular follow-up and self-monitoring

3.3. Nutritional status

3.4. Physical activity status

3.5. Lifestyle habits

3.1.1. Be able to follow medical advice and use medication accurately (ensure the frequency, dosage and duration of medication and do not stop medication without permission)

3.1.2. Do not take medication without the consent of a professional

3.1.3. Be aware of the possible side effects of taking immunosuppressive drugs

3.1.4. Be able to consult a professional before vaccination

3.2.1. To learn proper self-monitoring (e.g. blood pressure, temperature, weight, urine output)

3.2.2. Actively monitor indicators (e.g. blood pressure, temperature, weight, urine output) and know normal values

3.2.3. Follow up with your doctor and have a physical examination as required (every six months to a year, as required by your transplant surgeon)

3.2.4. Number of unscheduled readmissions after discharge from hospital

3.3.1. Blood glucose

3.3.2. Be able to opt for healthy foods and maintain a balanced diet (small, frequent meals, high quality protein, high calcium, low cholesterol, etc.)

3.3.3. Be able to avoid forbidden foods such as grapefruit and immune-enhancing health products such as ginseng, deer antler, royal jelly, etc

3.3.4. Body mass index

3.4.1. Self-care status

3.4.2. To know the type and amount of exercise that is appropriate for you at different stages after surgery

3.4.3. Appropriate exercise program in place and executed

3.4.4. To know the precautions for sex after transplantation

3.5.1. Quit smoking and restricted drinking

3.5.2. Regularity of routine

3.5.3. Sleep status

4. Social and Environment Domains

4.1. Healthcare resource utilization

4.2. Life environment

4.3. Social function

4.1.1. Be able to access solutions to post-transplant related questions and assistance from the hospital/community/public media (e.g. WeChat, etc.)

4.1.2. Be supported and assisted by disease-related national medical policies (e.g., health insurance, chronic disease and serious illness assistance, etc.)

4.1.3. Maintain favorable communication with health care professionals

4.2.1. The residential environment is clean, tidy and well ventilated

4.2.2. No allergenic substances (such as pollen, willow, animal hair, etc.) in the residential and occupational environment

4.3.1. Be able to obtain the support of family and friends

4.3.2. Be able to engage in normal social and leisure activities (if condition permits) (doing household chores, visiting friends and relatives, dining out, shopping, vacation, etc.)

4.3.3. Sharing experiences, questions and knowledge about kidney transplantation with fellow patients

5. Satisfaction

5.1. Transitional care services

5.2. Transitional care experience

5.1.1. Transitional care formats (e.g., mini-lectures, renal club, WeChat groups, brochures, micro-lessons, etc.)

5.1.2. Transitional care content (e.g., diet, exercise, drug knowledge, psychological support, etc.)

5.1.3. Consistent information from health care workers

5.2.1. Promptness, persistence and availability of transitional care

5.2.1. Attitudes of service when providing care