Multicentre Tasmanian Study of a Multidisciplinary Intervention to Reduce Readmission and Death of Patients admitted with Heart Failure

INTERVENTION: This approach will involve the following deviations from standard practice: 1. Pre‐discharge ‐ 1a. Discussion and assessment of palliative care needs. This will be performed by the physician or nurse on the care team, prompted by study co‐ordinator; ‐ 1b. Echocardiography (including pulmonary imaging) and/or BNP to ensure that the patient is as close as possible to euvolaemic before discharge. This will be performed by the physician or sonographer, prompted by study co‐ordinator; ‐ 1c. Assessment of risk based on clinical, cognitive and psychosocial factors. Clinical data will include patient history, medications, physical measurements, blood tests, and findings on echocardiography. Nonclinical data included age, sex, language background, marital status, living alone or with others, education, socioeconomic status, remoteness index (differentiating residence in a metropolitan, rural, or remote area of Australia), medical insurance, and any home health care services provided. Questionnaires used for data collection included the Montreal Cognitive Assessment (MoCA), Patient Health Questionnaire (PHQ‐9), and Generalized Anxiety Disorder (GAD‐7). This was obtained by the study co‐ordinator and communicated to the heart failure nurse. 2. Transition care ‐ A heart failure nurse who will follow the patient as both an inpatient and outpatient and act as a ’transition coach‘ to visit the patient in the hospital prior to discharge and ensure appropriate medication reconciliation, follow‐up plans, and education. 3. Follow‐up –The heart failure nurse will provide at least two calls (telephone and home visit) within the first 30 days to provide post‐discharge support. Surveillance over the next year will involve calls and/or home visits, monthly over the 1st 3 months, with frequency determined by the risk and status of the patient thereafter. Telemonitoring of weight and vital signs if needed. Assistance will be provided to maximize the likelihood of up‐titration of medications. 4. The heart failure nurse will be the first contact for changes in patient status and liaise with the cardiologists or Emergency Department (ED) if review rather than admission is needed; 5. Action plan ‐ Provision of clear instructions to patients and caretakers regarding personalized actions to take when weight or symptoms change. CONDITION: Heart Failure PRIMARY OUTCOME: All cause readmission (HF and non‐HF) and death at 90 days, assessed by data linkage to patient records All‐cause readmission (HF and non‐HF) or death at 30 days, assessed by data linkage to patient records SECONDARY OUTCOME: All cause readmission (HF and non‐HF) and death at 12 months, assessed by data linkage to patient records Days alive and out of hospital, assessed by data linkage to patient records Duke activity status index (DASI) Duke activity status index (DASI) ; General health status (EQ5D) General health status (EQ5D) ; ; Heart failure disease‐specific quality of life (Kansas City HF questionnaire) ; Heart failure disease‐specific quality of life (Kansas City HF questionnaire) INCLUSION CRITERIA: Admission to hospital with heart failure