Nurse-Led Heart Failure Care Transition Intervention for African Americans

描述（由申请人提供）：心力衰竭（HF）影响超过500万美国人，其发病率达到流行病的程度。非裔美国人（AA）的新发和复发性心衰事件（包括住院和死亡率）的年发生率更高。为了缓解症状而反复去急诊室和再次住院，导致心衰每年直接和间接的费用达到332亿美元。心衰再住院的常见原因包括症状识别的延迟，药物和饮食的不依从性，以及缺乏自我管理的知识和技能。有证据表明，在心衰护理机构中过渡的患者存在严重的质量缺陷，使他们面临分散护理的风险。分散的护理可能导致关于心衰自我管理的相互矛盾的建议，混淆的药物方案，很可能出现错误和重复，随访不足，以及在所有医疗保健机构中协调护理的患者和护理人员准备不足。护士提供的过渡性护理已被证明可以改善心衰的结果。患者导航员改善了癌症护理，社区卫生工作者改善了心血管风险管理，特别是在高危少数群体中；然而，患者导航员和社区卫生工作者模型尚未应用于心衰护理。有限的证据表明，远程监护可能是改善预后的有效策略，特别是对高危心衰患者。为了解决心衰护理方面的差距，我们建议完善和测试一种基于证据的心衰护理模式，该模式结合了包括远程医疗在内的最佳证据，以改善AAs的心衰护理过渡。这种创新的心衰护理过渡干预（hfti）将由护士-社区健康导航员团队向心衰患者及其护理人员提供。HFCTI的组成部分包括药物和症状自我管理支持、远程监测和个人心衰护理记录。将通过患者焦点小组以及住院和门诊临床医生利益相关者评估来完善《公约》。采用随机对照设计，我们将在指数住院出院后30、90和180天测试hfti对近端（心衰护理转变、心衰知识、心衰自我管理）和远端结局（再住院、急诊室就诊、功能状态和心衰相关生活质量）的影响。这种创新的、以患者为中心的、跨学科的心衰护理模式，重点是加强自我管理和远程医疗的使用，具有显著的潜力，可以改善心衰患者的自我管理和预后，这是一个不成比例的高风险人群。公共卫生相关性：心力衰竭（HF）影响着超过500万美国人，其发病率达到流行病的程度。非裔美国人（AA）的新发和复发性心衰事件（包括住院和死亡率）的年发生率更高。在这项研究中，我们建议测试一种创新的、以患者为中心的、跨学科的心衰护理模式，重点是加强自我管理和远程医疗的使用，这对心衰患者的自我管理和预后有很大的潜力，这是一个高危人群。

DESCRIPTION (provided by applicant): Heart failure (HF) affects over 5 million Americans with HF morbidity reaching epidemic proportions. Annual rates of new and recurrent HF events including hospitalization and mortality are higher among African Americans (AA). Repeated emergency room (ER) visits and rehospitalizations for symptom relief contribute to the $33.2 billion direct and indirect annual costs of HF. Common reasons for HF rehospitalization include delays in symptom recognition, medication and dietary noncompliance, and lack of knowledge and skills for competent self management. Evidence suggests that serious deficiencies in quality exist for patients undergoing transition across HF care settings, placing them at risk from fragmented care. Fragmented care can result in conflicting recommendations regarding HF self management, confusing medication regimens with high potential for error and duplication, inadequate follow-up, and inadequate patient and caregiver preparation to coordinate care among all healthcare settings. Transitional care delivered by nurses has been demonstrated to improve HF outcomes. Patient navigators have improved cancer care and community health workers have improved cardiovascular risk management, particularly among high risk minority populations; however, the patient navigator and community health worker models have not been applied to HF care. Limited evidence suggests that telemonitoring may be an effective strategy for improving outcomes, particularly in high risk HF patients. To address the gaps in HF care, we propose to refine and test an evidence-based HF care model that incorporates the best evidence, including telehealth, to improve HF care transition for AAs. This innovative HF care transition intervention (HFCTI) will be delivered by a nurse-community heath navigator team to AAs with HF and their caregivers. Components of the HFCTI include medication and symptom self management support, telemonitoring, and a personal HF care record. The HFCTI will be refined through patient focus groups and inpatient and outpatient clinician stakeholder assessments. Using a randomized controlled design, we will test the effect of the HFCTI on proximal (HF care transition, HF knowledge, HF self management) and distal outcomes (rehospitalization, ER visits, functional status, and HF-related quality of life) at 30, 90, 180 days after discharge from index hospitalization. This innovative, patient-centered, interdisciplinary model for HF care, with focus on enhancing self management and use of telehealth, has significant potential to improve self management and outcomes among AAs with HF, a population at disproportionately high risk. PUBLIC HEALTH RELEVANCE: Heart failure (HF) affects over 5 million Americans with HF morbidity reaching epidemic proportions. Annual rates of new and recurrent HF events including hospitalization and mortality are higher among African Americans (AA). In this study, we propose to test an innovative, patient-centered, interdisciplinary model for HF care, with focus on enhancing self management and use of telehealth, which has significant potential to improve self management and outcomes among AAs with HF, a population at disproportionately high risk.