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，HF发病率达到流行病比例。非裔美国人（AA）新发和复发HF事件（包括住院和死亡）的年发生率较高。为缓解症状而重复急诊室（ER）就诊和再住院导致HF的直接和间接年度费用为332亿美元。HF再住院的常见原因包括症状识别延迟、药物和饮食不依从以及缺乏胜任自我管理的知识和技能。有证据表明，在HF护理环境中进行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HF自我管理方面的建议相互矛盾，混淆药物治疗方案，错误和重复的可能性很高，随访不充分，患者和护理人员准备不足，无法在所有医疗机构中协调护理。护士提供的过渡性护理已被证明可以改善HF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，特别是在高风险少数人群中;然而，患者导航员和社区卫生工作者模型尚未应用于HF护理。有限的证据表明，远程监护可能是改善结局的有效策略，特别是在高风险HF患者中。为了解决HF护理中的差距，我们建议完善和测试基于证据的HF护理模式，该模式包含最佳证据，包括远程医疗，以改善AA的HF护理过渡。这种创新的HF护理过渡干预（HFCTI）将由护士-社区健康导航员团队向患有HF的AA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，远程监护和个人HF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。采用随机对照设计，我们将测试HFCTI在首次住院出院后30、90、180天时对近端（HF护理过渡、HF知识、HF自我管理）和远端结局（再住院、ER访视、功能状态和HF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HF护理模式，重点是加强自我管理和远程医疗的使用，具有显着的潜力，以改善自我管理和结果之间的AA与HF，人群在不成比例的高风险。公共卫生相关性：心力衰竭（HF）影响超过500万美国人，HF发病率达到流行病比例。非裔美国人（AA）新发和复发HF事件（包括住院和死亡）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，跨学科的HF护理模式，重点是加强自我管理和远程医疗的使用，这对改善患有HF的AA人群的自我管理和结局具有重大潜力，这是一个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.