The primary goal of this research project is to improve the health status and decrease hospitalization and death for patients discharged with heart failure (HF) via education to patients, disease monitoring and medication titration through shared medical appointments (SMAs). Studies have found patient self-care behaviors in HF (e.g. medication/dietary noncompliance) and health system factors (e.g. care discoordination, limited access, lack of education to patients and caregivers) played an important role in patient's health status and hospitalization risk to the extent that 50% of the readmissions were judged to be possibly/probably preventable. To address patient and system factors based on the Chronic Care Model, redesign of care delivery, via SMA's, can be a good solution to provide patient self- management support while also performing disease monitoring and medication management in an environment of peer support. We propose a randomized controlled trial to enroll patients within 6 weeks of discharge from a HF hospitalization and randomized them to receive either SMA intervention every other week for 8 weeks versus usual care for HF. We will determine, at 180 days from randomization, whether HF patients who participate in HF-SMA, as compared to patients who receive usual care: 1) Experience better cardiac health status measured by Kansas City Cardiomyopathy Questionnaire (primary outcome), and overall health status (EQ5D, secondary outcome); 2) Have fewer hospitalization or death and 3) Experience improvement in intermediate outcomes: a) increase in HF Self-Care behavior, and b) decrease in plasma BNP levels. For patients who underwent HF-SMA, we will also determine perceived benefits, areas in need of improvement, potential obstacles of implementation, and fidelity of the intervention across sites, by conducting (a) face-to-face interviews with patients and (b) telephone interviews with stakeholders (physicians of the patients and administrators). The sites will be Providence VA and Phoenix VA hospitals to enroll a total of 375 patients. The study duration will be 180 days for all patients from the time of randomization. We will use stratified (enrollment in other programs for HF care, <2 hospitalizations last 6 months, left ventricular ejection fraction <40%), block randomization with block sizes of 4 in each site to ensure balance of the stratified variables. The team will consist of a nutritionist, nurse, health psychologist an a clinical pharmacist or nurse practitioner, without the presence of a physician (cardiologist will b available on call). The session will start with an assessment of patient needs followed by pre-assigned theme-based disease self-management education, followed by patient-initiated disease management discussion, and conclude with break-out sessions of individualized medication case management. Our study findings will be used in health care management and system redesign to provide better quality and patient centered care for our veterans with HF. The long-term goal is to use a multi-disciplinary team approach in a group setting to manage HF support regular physician visits, in a peer support environment, all of which, are necessary to provide patient- centered care and improve outcomes.

Public Health Relevance

The primary goal of this proposal is to improve the quality of care and outcomes for patients discharged with heart failure using an innovative multidisciplinary group intervention approach. Heart failure is a complex chronic illness where comprehensive patient-centered care is difficult and resource intensive. One potential solution is to use shared medical appointments (SMA), where a multi-disciplinary team of providers with expertise in nutrition, nursing, behavior and medication management join to manage heart failure in addition to and support of, the patient's regular physician visits. We will enroll patients from Providence and Phoenix VA Hospitals who were within 6 weeks of discharge from a heart failure hospitalization and randomized them to receive SMA intervention or usual care. Results from this project are expected to add an innovative intervention that could improve outcomes important for both the patient and the VA: health status, hospitalizations, and mortality.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HSR-1 Medical Care and Clinical Management (HSR1)
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Providence VA Medical Center
United States
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