Hackensack Meridian Health
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 Transitions of Care Clinic (TOCC) which was recently introduced in our institution, to bridge the gap in care between hospital discharge to home and connect discharged patients to the outpatient provider focusing on patients with heart failure (HF). The existing TOCC seeks to improve transitions of care by providing patients with the education, tools, and resources to help manage their chronic disease. With this project, we propose to expand TOCC by offering extensive education to patients via iPad videos and providing them with HF kits prior to their discharge. We will also connect patients to outpatient providers, assist with scheduling appointments and follow up with patients after the appointment takes place to re-evaluate their needs to discuss short- and long-term care plans. By targeting patients being treated for acute exacerbation of heart failure with preserved ejection fraction (HFpEF), this program aims to facilitate the transition of care, reduce hospital readmissions and improve patients' quality of life and satisfaction. The kits will provide essential tools for self-management such as monitoring daily weights, monitoring fluid intake, and vital signs. Patients provided with a kit will receive an initial phone call from TOCC within 24 to 72 hours of discharge and an additional phone call will be made prior to 30-days post discharge. The funding provided by this grant will facilitate care coordination, enhance the TOCC program, and improve community health, ultimately demonstrating the need for further external funding.
Heart Failure With Preserved Ejection Fraction
HF Kit and Follow-ups
NA
| Study Type : | INTERVENTIONAL |
| Estimated Enrollment : | 150 participants |
| Masking : | NONE |
| Primary Purpose : | HEALTH_SERVICES_RESEARCH |
| Official Title : | Impact of Multidisciplinary Transitions of Care Clinic on Readmission Rates for Patients With Heart Failure With Preserved Ejection Fraction at a University Medical Center |
| Actual Study Start Date : | 2025-05-15 |
| Estimated Primary Completion Date : | 2026-09-15 |
| Estimated Study Completion Date : | 2026-09-15 |
Information not available for Arms and Intervention/treatment
| Ages Eligible for Study: | 18 Years to 90 Years |
| Sexes Eligible for Study: | ALL |
| Accepts Healthy Volunteers: |
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Ocean University Medical Center
Brick, New Jersey, United States, 08724