A Trial of Heart Failure Disease Management in Skilled Nursing Facilities

描述（由申请人提供）：大约25%的因心力衰竭住院的医疗保险患者出院到专业护理机构， 过去10年这些患者的再住院率和死亡率高于出院回家的患者。熟练的护理设施作为虚弱的心力衰竭患者的过渡场所，他们在住院后恢复功能和独立性。医疗保险允许住院后长达100天的熟练护理。虽然针对老年人的心力衰竭疾病管理计划的好处已经在其他环境中建立，但很少有证据表明现代心力衰竭管理整合到专业护理机构提供的护理中。 本研究是一项1：1随机分组试验，旨在研究心力衰竭疾病管理计划对专业护理机构心力衰竭患者的影响。护理病人的医生将作为集群，每个熟练的护理设施作为街区。每名医生将被随机分配，根据心力衰竭疾病管理计划或常规护理来管理他们的患者。主要目的是确定心力衰竭疾病管理计划是否会降低全因住院、急诊就诊和死亡率的复合结局。次要目的是确定心力衰竭疾病管理计划是否1）改善患者的健康状况和心力衰竭自我护理能力，2）使患者更有可能回家，而不是出院到机构，3）具有成本效益。本研究的主要假设是心力衰竭疾病管理计划将减少复合结局中的事件。心力衰竭疾病管理计划基于心力衰竭的最佳实践，包括心力衰竭护理的7个要素：记录射血分数、症状和活动评估、每日体重/饮食监测、药物滴定、患者和护理人员教育、出院指导和SNF出院后7天内的随访访视。一名经过专业培训的心力衰竭护士将与医生密切合作。心力衰竭护士倡导者将负责该计划的所有元素，以确保忠诚度 的干预。本研究的结果将确定在专业护理机构实施的心力衰竭疾病管理计划是否能改善患者的预后，并且具有成本效益。这些结果将有可能通过改变在美国专业护理机构接受护理的老年人的心力衰竭护理来产生巨大的公共卫生影响。

DESCRIPTION (provided by applicant): Approximately 25% of Medicare patients hospitalized with heart failure are discharged to skilled nursing facilities and the numbers have tripled in the last 10 years. These patients have higher rehospitalization rates and mortality than those patients who are discharged to home. Skilled nursing facilities serve as a transitional site for debilitated heart failure patients where they regain function and independence following a hospitalization. Medicare allows up to 100 days of skilled nursing care post-hospitalization. Although the benefits of heart failure disease management programs targeted to the elderly have been established in other settings, there is little evidence of contemporary heart failure management integrated into the care delivered in the skilled nursing facilities. The proposed study is a 1:1 randomized cluster trial to study the effect of a heart failure disease management program for heart failure patients in skilled nursing facilities. The physicians who care for patients will serve as the cluster and each skilled nursing facility as the block. Each physician will be randomized to either manage their patients according to a heart failure disease management program or to usual care. The primary objective is to discern if a heart failure disease management program will decrease the composite outcome of all-cause hospitalizations, emergency department visits and mortality. The secondary objectives are to determine if a heart failure disease management program 1) improves patients' health status and heart failure self-care ability, 2) makes it more likely a patient will return home, rather tha be discharged to a facility and 3) is cost-effective. The primary hypothesis for this study is thata heart failure disease management program will decrease events in the composite outcome. The heart failure disease management program is based on best practices for heart failure and includes 7 elements of heart failure care: documentation of ejection fraction, symptom and activity assessment, daily weights/dietary surveillance, medication titration, patient and caregiver education, discharge instructions and a follow up visit within 7 days post-SNF discharge. A specialty trained heart failure nurse advocate will work closely with physicians. The heart failure nurse advocate will be responsible for all elements of the program to ensure fidelity of the intervention. Results from this study will determine if a heart failure disease management program in skilled nursing facilities improves patient outcomes and is cost-effective. These results will have the potential to have a large public health impact by transforming heart failure care for older adults who are cared for in skilled nursing facilities in the United States.