This caregiver-oriented discharge planning program, with its emphasis on individualised health education and home visits following discharge may improve caregivers' preparation and the satisfaction of their needs during the discharge transition.

The self-management programme improved self-efficacy for salt and fluid control, self-management behaviours, and decreased heart failure-related symptoms in older Taiwanese outpatients with heart failure. Nursing interventions to improve health-related outcomes for patients with heart failure should emphasize self-efficacy in the self-management of their disease.

Nurses can help older persons identify factors that relate to their nutritional status and plan effective interventions to maintain healthy nutrition behaviours with the following risk characteristics: (1) lower level of education, (2) more chronic diseases and (3) external control orientation.