Telemedicine Collaboration Model to Support Patients with Frequent Heart Failure and Atrial Fibrillation Hospital Admissions

What this Trial Is About

This research aims to explore how a telemedicine-based cross-sector collaboration model can manage patients with frequent hospital admissions due to decompensated heart failure or atrial fibrillation treated with loop-diuretics. It focuses on identifying conditions that make these patients vulnerable and describing key elements that enable successful management with the cardio-share model. The study observes patients admitted to a single hospital site who have recent or repeated admissions for heart failure. During hospital admission, patients receive help to use telemedicine tools called MinSP-Ass., which allows them to access educational materials and report vital signs and symptoms. The model involves communication between hospital cardiologists, general practitioners, and community health workers who assist patients at home or in elderly homes. Teleconsultations and messaging support are offered to primary care providers before discharge, aiming for shared management responsibility. Participants demographics, vital signs, lab tests, medication, and hospital readmissions are recorded at discharge, three months, and six months after admission. Researchers will compare readmission rates and quality of life before and after the cardio-share models implementation. Data collection includes factors contributing to vulnerability, use of heart medicines, and healthcare visits. The study monitors days spent out of hospital as the main outcome over six months.

The Cardio-share Telemedicine Cross-sector Collaboration Model for Managing Vulnerable Patients With Heart Failure