Impact of Multidisciplinary Transitions of Care Clinic on Readmission Rates for Patients With Heart Failure With Preserved Ejection Fraction at a University Medical Center
试验速览
- 阶段
- 不适用
- 状态
- 终止
- 入组人数
- 69
- 试验地点
- 1
- 主要终点
- All-cause 30-day hospital readmission rate for heart failure
研究概览
简要总结
The transition period from hospital to home is a time of heightened risk for patients to experience adverse events, medication errors, and readmission to the hospital. Patients at the highest risk include older adults and patients with low health literacy, socioeconomic disadvantages, and/or multiple comorbidities. This project proposes to expand the existing Transitions of Care Clinic (TOCC) which was recently introduced in our institution in 2024, to bridge the gap in care between hospital discharge to home and connect discharged patients to their outpatient providers with a focus on patients with heart failure (HF).
The existing TOCC, a multidisciplinary team composed of a pharmacist and a nurse practitioner, seeks to improve the services that are currently being provided to patients and enhance the transitions of care process by providing patients with education, tools, and resources to help manage their chronic disease. With this study, we propose to expand TOCC by offering extensive education to patients via iPad videos and providing them with HF tool kits prior to their discharge. We will also assist with scheduling follow appointments with their outpatient providers and follow up with patients after the appointment takes place to re-evaluate their needs and reinforce self management of heart failure.
By targeting patients being treated for acute exacerbation of heart failure with preserved ejection fraction (HFpEF), this study aims to facilitate the transition of care, reduce hospital readmissions and improve patients' quality of life and satisfaction. Patients with HFpEF represent a majority of the HF patients that are readmitted at OUMC. HFpEF patients have fewer guideline recommended treatments and represent a vulnerable patient population. The HF tool kits will provide these patients with the essential tools, resources, and log sheets for self-management such as monitoring daily weights, monitoring blood pressure and heart rate. Patients provided with a kit will receive an initial phone call from TOCC within 1 to 3 days of discharge and a second phone call within 21-24-days post discharge.
研究设计
- 研究类型
- Interventional
- 分配方式
- Non Randomized
- 干预模型
- Parallel
- 主要目的
- Health Services Research
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 90 Years（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Adults ages 18 to 90 years old discharged from Ocean University Medical Center (OUMC)
- •Inpatient admission for heart failure with preserved ejection fraction (HFpEF) exacerbation
- •Patient discharged home with or without homecare
排除标准
- •Refuse to participate in TOCC phone calls
- •Discharged to a facility
- •Discharged with homecare services
- •Discharged on hospice services
- •Hemodialysis
- •Leave against medical advice (AMA)
- •Diagnosed with dementia
- •Without medical capacity or unable to provide own consent
研究组 & 干预措施
Active Cohort - Heart Failure (HF) Kit
Extensive education to patients via iPad videos and providing them with HF kits prior to their discharge. Structured follow up post discharge and linkage to care.
干预措施: HF Kit and Follow-ups (Behavioral)
Historical controls
Standard of care education and follow up
结局指标
主要结局
All-cause 30-day hospital readmission rate for heart failure
时间窗: 30 days post discharge
This measures the percentage of patients initially hospitalized for HF who are readmitted to the hospital for any reason within 30 days of discharge. This is a standard metric for evaluating HF care and aligns directly with the objective of reducing readmissions.
次要结局
- 7-Day Provider Follow-Up(7 day post discharge)
- Patient Satisfaction with Transition of Care(31 to 45 days post discharge)