NCT02112227

Patient-centered Care Transitions in Heart Failure: A Pragmatic Cluster Randomized Trial

Patient-centered Care Transitions in Heart Failure: A Pragmatic Cluster

• Status: Completed
• Phase: N/A
• Study type: Interventional
• Enrollment: 3,500 (actual)
• Sponsor: Population Health Research Institute · Academic / Other
• Sex: All
• Age: 16 Years
• Healthy volunteers: Not accepted

Summary

Heart failure (HF) is the most common cause of hospitalization in older adults. The month after hospital discharge represents a vulnerable period, when patients are at increased risk of death and readmission to hospital. Research has shown that certain discharge-planning services can reduce death and readmissions, but these have not been widely implemented. In this study, we will group evidence-informed discharge-planning services into 'Patient-centered Care Transitions in HF' (PACT-HF), a model of care that will prepare patients for their transition from hospital to home. Through PACT-HF, patients will benefit from a comprehensive assessment of their health care needs, learn to recognize and manage symptoms of HF, and receive the information and follow-up care needed to optimize their health. We will introduce PACT-HF to 10 Ontario hospitals over a number of time periods using a stepped wedge cluster trial design. We will compare the outcomes (hierarchically ordered) of patients in hospitals with PACT-HF to those in hospitals without PACT-HF. We anticipate that patients hospitalized at the sites with PACT-HF will have fewer readmissions, emergency visits, and deaths after discharge; report a better quality of life; and feel more prepared for discharge. We also anticipate that overall, PACT-HF will reduce health system costs.

Conditions

• Heart Failure

Interventions

Type	Name	Description
OTHER	PACT-HF Model	PACT-HF Model includes the following 1) comprehensive patient assessment 2) self-care education 3) patient-centered discharge summary 4) early follow up with FP 5) referral of high-risk patients to regional multidisciplinary HF clinic and to nurse-led home care

Timeline

• Start date: 2015-03-01
• Primary completion: 2016-02-29
• Completion: 2016-06-01
• First posted: 2014-04-11
• Last updated: 2018-04-05

Locations

1 site across 1 country: Canada