Study on Multidisciplinary Transitions of Care Clinic to Reduce Readmissions for Heart Failure With Preserved Ejection Fraction Patients

What this Trial Is About

Researchers are evaluating an expanded Transitions of Care Clinic TOCC program aimed at improving care for patients with heart failure with preserved ejection fraction HFpEF during the vulnerable period after hospital discharge. This study focuses on reducing hospital readmissions and enhancing quality of life for patients treated for acute exacerbations of HFpEF, a group with limited treatment options and high readmission rates. The TOCC team includes a pharmacist and nurse practitioner who provide education, tools, and resources to support patients chronic disease management. Participants receiving the TOCC intervention will watch educational videos on an iPad and receive a heart failure HF kit containing essential tools and log sheets for self-monitoring daily weight, blood pressure, and heart rate before discharge. The program also includes scheduling follow-up appointments with outpatient providers and structured follow-up phone calls from the TOCC team at 1 to 3 days and again at 21 to 24 days post discharge to review instructions, medication education, and assess clinical status. A comparison group will receive standard education and follow-up care. During the study, participants will be monitored for hospital readmission within 30 days post discharge as the primary outcome. Secondary measures include follow-up with providers within 7 days after discharge and patient satisfaction with the transition of care within 31 to 45 days. The study spans from hospital discharge through roughly six weeks of follow-up, tracking adherence and patient needs to improve self-management and continuity of care.

Transitions of Care Clinic (TOCC)