Integrated Healthcare Program for Adults With Severe Frailty and Heart Failure Evaluating Coordinated Care and Follow-Up by Interdisciplinary Teams

What this Trial Is About

Researchers are evaluating integrated healthcare services for patients with severe frailty and heart failure. This proof-of-concept study aims to assess the effect of coordinated, interdisciplinary follow-up teams that work across healthcare settings to address patients needs, goals, and risks. The study responds to a need for clinical trials that focus on frail patients with heart failure, who are often excluded from large cardiovascular studies, with the goal of improving symptom burden, quality of life, and healthcare outcomes. The intervention involves developing a personalized treatment and follow-up plan tailored to each patients co-morbidities, risk areas, cognitive and functional status, symptoms, and needs. An interdisciplinary team from the hospital and primary care collaborates on this plan. Close relatives are encouraged to participate. Follow-up is conducted at least monthly by nurses in the community through phone calls or home visits, with adjustments made as needed. A matched control group will be included from an ongoing randomized trial for comparison. Participants will be assessed at baseline, and then monitored at weeks 6, 12, and 52. Researchers will measure changes in symptom control, patient satisfaction, health-related quality of life, and caregiver distress. Hospitalization data, including unplanned readmissions and total hospital days lost, will also be collected. The studys duration includes follow-ups up to one year to evaluate the feasibility and impact of the integrated care approach on patients with severe frailty and heart failure.

INTEgRated Health CARE for Patients With Frailty and Heart Failure