Transitions of Care for Heart Failure
Trial Summary
What is the purpose of this trial?
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.
Will I have to stop taking my current medications?
The trial information does not specify whether you need to stop taking your current medications. It focuses on providing education and resources for managing heart failure after hospital discharge.
What data supports the effectiveness of the HF Kit treatment for heart failure?
The research highlights that effective transitional care interventions, such as early symptom identification and follow-up appointments, improve quality of life and reduce hospitalizations for heart failure patients. Additionally, participation in performance improvement registries has been associated with better use of recommended therapies and improved outcomes for heart failure patients.12345
Is the HF Kit treatment generally safe for humans?
What makes the HF Kit treatment unique for heart failure?
The HF Kit treatment is unique because it focuses on improving the transition of care from hospital to home for heart failure patients, which is a high-risk period for re-hospitalization and death. It combines healthcare services and interventions, such as early symptom identification and follow-up care, to enhance patient understanding and management of their condition, unlike standard treatments that may not emphasize transitional care.13111213
Research Team
Alexandria Berns, PharmD
Principal Investigator
Hackensack Meridian Health
Eligibility Criteria
The TOCC program is designed for patients with heart failure who are transitioning from hospital to home. It's especially aimed at older adults and those with low health literacy, socioeconomic challenges, or multiple health conditions. The goal is to help these individuals manage their condition better after they leave the hospital.Inclusion Criteria
Exclusion Criteria
Timeline
Screening
Participants are screened for eligibility to participate in the trial
Education and Discharge Preparation
Participants receive extensive education via iPad videos and are provided with HF tool kits prior to discharge
Initial Follow-up
Participants receive an initial phone call from TOCC within 1 to 3 days of discharge to assess needs and reinforce self-management
Secondary Follow-up
Participants receive a second phone call from TOCC within 21-24 days post discharge to re-evaluate needs and reinforce self-management
Follow-up
Participants are monitored for satisfaction and readmission rates, with a focus on reducing hospital readmissions and improving quality of life
Treatment Details
Interventions
- HF Kit
Find a Clinic Near You
Who Is Running the Clinical Trial?
Hackensack Meridian Health
Lead Sponsor
New Jersey Health Foundation
Collaborator
New Jersey Health Foundation
Collaborator