- 作者：Rebecca S. Boxer ; Mary A. Dolansky ; Christine A. Bodnar ; Mendel E. Singer ; Jeffery M. Albert ; Stefan Gravenstein
- 关键词：Heart failure ; disease management ; SNF
- 刊名：Journal of the American Medical Directors Association
- 出版年：2013
- 出版时间：September, 2013
- 年：2013
- 卷：14
- 期：9
- 页码：710.e5-710.e11
- 全文大小：320 K
Background
Heart failure (HF) disease management can improve health outcomes for older community dwelling patients with heart failure. HF disease management has not been studied in skilled nursing facilities, a major site of transitional care for older adults.Methods and anticipated results
The objective of this trial is to investigate if a HF- disease management program (HF-DMP) in skilled nursing facilities (SNF)s will decrease all-cause rehospitalizations for the first 60 days post-SNF admission. The trial is a randomized cluster trial to be conducted in 12 for-profit SNF in the greater Cleveland area. The study population is inclusive of patients with HF regardless of ejection fraction but excludes those patients on dialysis and with a life expectancy of 6 months or less. The HF-DMP includes 7 elements considered standard of care for patients with HF documentation of left ventricular function, tracking of weight and symptoms, medication titration, discharge instructions, 7-day follow-up appointment post-SNF discharge, and patient education. The HF-DMP is conducted by a research nurse tasked with adhering to each element of the program and regularly audited to maintain fidelity of the program. Additional outcomes include health status, self-care management, and discharge destination.
Conclusions
The SNF-Connect Trial is the first trial of its kind to assess if a HF-DMP will improve outcomes for patients in SNFs. This trial will provide evidence on the effectiveness of HF-DMP to improve outcomes for older frail HF patients undergoing postacute rehabilitation.