Nurse-Led Heart Failure Care Transition Intervention for African Americans
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 11
- 试验地点
- 1
- 主要终点
- Rehospitalization
研究概览
简要总结
Heart failure (HF) affects over 5 million Americans with HF morbidity reaching epidemic proportions. Annual rates of new and recurrent HF events including hospitalization and mortality are higher among African Americans. In this study, the investigators are testing an interdisciplinary model for heart failure care, with focus on enhancing self management and use of telehealth, which has significant potential to improve self management and outcomes.
The main purpose of this study is to learn how to help African Americans with heart failure care for themselves at home. We hope to find out if a team including a nurse and community health navigator using a computer telehealth device can help people with heart failure stay healthier. The team will help people with heart failure to manage their medication, monitor their symptoms and weigh themselves every day after they leave the hospital. The team will also help people with heart failure learn to solve problems that may keep them from following their treatment plan.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Supportive Care
- 盲法
- Single (Outcomes Assessor)
入排标准
- 年龄范围
- 21 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •hospitalized with admitting diagnosis of heart failure in prior 8 weeks
- •self-identified as African American
- •community-dwelling (i.e., not in a long-term care facility)
- •residence within a predefined radius in Baltimore City
- •working telephone in their home
- •provide signed informed consent
排除标准
- •cannot speak or understand English
- •severe renal insufficiency requiring dialysis
- •acute myocardial infarction within preceding 30 days
- •receiving home care services for HF post discharge
- •legally blind or have major hearing loss
- •screen positive for cognitive impairment on the Mini-cog at baseline
- •unable to stand independently on a weight scale (limited ability to participate in HAT system)
- •weigh more than 325 pounds (exceed scale capacity)
- •serious or terminal condition such as psychosis or cancer (actively receiving chemo or radiation)
研究组 & 干预措施
Heart Failure Self Care Support
The goal of the Heart Failure Self Care Support Intervention (Navigator Program), delivered by a nurse and community health navigator team over 3 months post discharge from the index hospitalization, was to improve care transitions by providing patients with tools and support that promote knowledge and skills for HF self care as they transition from hospital to home. The multifaceted Navigator Intervention included the following intervention components: HF home automated telemonitoring support, medication and symptom self management, patient-centered record, HF care follow up, and activation of key supporter.
干预措施: Heart Failure Self Care Support (Behavioral)
Usual Heart Failure Care
Usual care for HF patients included the following: 1) Referral to HF clinic if the patient has no usual source of HF outpatient care, 2) HF patient education by HF care coordinator (advanced practice nurse), and 3) HF self care guide. All participants were treated by their usual source of HF care in the usual manner.
干预措施: Usual heart failure care (Other)
结局指标
主要结局
Rehospitalization
时间窗: 3 months post enrollment
Rehospitalization with primary diagnosis of heart failure
次要结局
未报告次要终点