Nurse-Led Heart Failure Care Transition Intervention for African Americans

描述(由申请人提供)：心力衰竭(HF)影响着500多万美国人，心力衰竭的发病率达到流行病的程度。在非裔美国人(AA)中，包括住院和死亡率在内的新发和复发心力衰竭事件的年发生率较高。反复的急诊室就诊和为缓解症状而再次住院导致每年332亿美元的心衰直接和间接成本。心力衰竭再住院的常见原因包括症状识别延迟、服药和饮食不合规，以及缺乏有效自我管理的知识和技能。有证据表明，对于正在经历跨心衰护理环境过渡的患者，存在严重的质量缺陷，将他们置于分散护理的风险中。零散的护理可能导致关于心力衰竭自我管理的相互矛盾的建议，混淆的药物治疗方案具有很高的出错和重复的可能性，不充分的后续行动，以及不充分的患者和护理人员准备来协调所有医疗保健环境中的护理。由护士提供的过渡性护理已被证明可以改善心力衰竭的结局。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，特别是在高危少数人群中；然而，患者导航员和社区卫生工作者模式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，特别是在高危心力衰竭患者中。为了解决心力衰竭护理方面的差距，我们建议完善和测试一种基于证据的心力衰竭护理模式，该模型结合了包括远程医疗在内的最佳证据，以改善AA患者的心力衰竭护理过渡。这一创新的心衰护理过渡干预(HFCTI)将由护士-社区健康导航员团队提供给心衰患者协会及其照顾者。HFCTI的组成部分包括药物和症状自我管理支持、远程监测和个人心力衰竭护理记录。HFCTI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进行完善。使用随机对照设计，我们将测试HFCTI对出院后30、90、180天的近端(心力衰竭护理转变、心力衰竭知识、心力衰竭自我管理)和远端结局(再住院、急诊室就诊、功能状态和心力衰竭相关生活质量)的影响。这种创新的、以患者为中心的跨学科心力衰竭护理模式，专注于加强自我管理和远程医疗的使用，具有显著的潜力来改善心力衰竭患者的自我管理和预后，心力衰竭是一个不成比例的高风险人群。公共卫生相关性：心力衰竭影响了500多万美国人，心力衰竭的发病率达到了流行病的程度。在非裔美国人(AA)中，包括住院和死亡率在内的新发和复发心力衰竭事件的年发生率较高。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心力衰竭护理模式，重点是加强自我管理和远程医疗的使用，这具有显著的潜力来改善患有心力衰竭的AA患者的自我管理和预后，心力衰竭是一种不成比例的高风险人群。

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.