Transitions of Care Clinic (TOCC)

Официальное название

Impact of Multidisciplinary Transitions of Care Clinic on Readmission Rates for Patients With Heart Failure With Preserved Ejection Fraction at a University Medical Center

Обзор

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.

Вмешательства

• Поведенческое HF Kit and Follow-ups
  These patients will receive TOCC intervention, which includes: pre-discharge introduction to the program; watching educational videos about heart failure via Mytonomy; receiving the American Heart Association's "Get With The Guidelines" (GWTG) booklet and a heart failure (HF) kit. These patients will receive a follow-up phone call days 1 to 3 days post discharge from the pharmacist and nurse practitioner to review discharge instructions, provide medication education, and assess clinical status;

Первичные конечные точки

• All-cause 30-day hospital readmission rate for heart failure [Срок оценки: 30 days post discharge]

Вторичные конечные точки (2)

• 7-Day Provider Follow-Up [Срок оценки: 7 day post discharge]
• Patient Satisfaction with Transition of Care [Срок оценки: 31 to 45 days post discharge]

Критерии участия

Критерии включения

• 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

Критерии исключения

• 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)
• Pregnant
• Diagnosed with dementia
• Without medical capacity or unable to provide own consent

Критерии приведены из реестра в оригинале (на английском). Окончательную оценку соответствия проводит исследовательский центр.

Здоровые добровольцы: Нет

Дизайн исследования

Распределение

Нерандомизированное

Модель

Параллельные группы

Маскирование

Открытое

Основная цель

Организация здравоохранения

Центры проведения

США · 1 центр

• Ocean University Medical Center — Brick

Идентификаторы

NCT: NCT06937827 · Pro2025-0058

Первоисточники (государственные реестры)

• ClinicalTrials.gov (NIH, США)

Открыть это исследование на ClinicalTrials.gov ↗