Paradigm Shift – Inpatient towards outpatient and community oriented care on heart failure patients Prepared by Camille K T HO Acknowledgement • • • • • • • Dr. S C LEUNG (HCE) Dr. W H CHOW (COS) Dr. E CHAU (SMO) Ms C L LEE (DOM) Ms W HUNG (GMN) Prof. F Wong All members of the team (CMU) Introduction • Heart failure is a common and costly cause of admissions to hospitals each year • The cost of heart failure is increasing because the population is living longer (Stewart et al 2002) Introduction Patients with congestive heart failure = $$$ Unplanned admissions Unplanned follow ups Reduce quality of life Significant morbidity In Hong Kong, the overall incidence was 0.7 per 1,000 population admitted to hospitals due to heart failure, with plenty of readmissions and unplanned follow up. These preventable negative factors include noncompliance with medications or diet, inadequate discharge planning or follow up, and failure to seek medical attention promptly when symptoms recur. (Leung et al 2004) Purposes of the program • Empowering the patients in self-management of their heart failure symptoms • Improve their quality of life • Promote their care in the community • Reduce the unplanned readmissions and follow up Expected Results • • • • • • • ↑↑ Treatment compliance Better symptoms control Increase exercise capacity Improve NYHAFC ↓↓ frequency of unplanned follow up ↓↓ unplanned readmission Transfer back to general cardiac care Methods Participants’ selection criteria • >18 • M/F • NYHAFC 2-4 • CAN READ AND WRITE CHINESE • PRIMARY DIAGNOSIS OF HEART FAILURE • REGULAR FU in GH Heart Failure Clinic Methods Flow for Heart Failure Clients Home-based Monitoring Program Initial assessment by SMO/Patient Educator (PE) of CMU, GH, in the HFC for suitable participants unsuitable candidates suitable candidates Baseline assessment of patient’s condition obtained PE (Nurse) conduct patient education program for client enrolled in the home-based monitoring program (Refer to appropriate allied health care professionals prn) Patient home–based Monitoring program with Tele-nursing by PE continue follow up in the HFC Methods 1. • • • • • • • • Assessment protocol Physical examinations Daily body weight Daily fluid balance Drug compliance Dietary compliance Exercise tolerance Unwanted habits Quality of life assessment Methods 2. • • • • • Apparatus and Measuring Instruments Blood pressure monitoring device Logbook with fluid balance charts Quality of life assessment test Weight Scales ± Cardiopulmonary exercise test Data analysis of the self-management program • • • • • • • • • Intake and Output balance Symptoms control Exercise capacity Behavior modification Drug compliance Dietary compliance NYHAFC status The frequency of unplanned FU / hospitalization The length of follow up period Results Patient Population • From March 2004 to September 2004 • 31 patients within the selection criteria were recruited at convenience sampling • Age • 20 – 65 • Mean age 47.3 ± 10.9 • Sex • Male 26 • Female 5 Results Marital status • Single 7 • Married 20 • Divorce 1 Results • • • • • Etiology of heart failure were: Ischaemic cardiomyopathy = 12.9% Dilated cardiomyopathy = 70.9% Acquired valvular disease = 12.9% Others = 3.3% Results Pre program Mean ejection fraction = 34.54 ± 10.8% Post program = 42.05 ± 11.8% p=0.003 NYHAFC • Class I 0% • Class II 16.1% • Class III 71% • Class IV 12.9% 6.9% 79.3% 13.7% 0% p<0.001 Results Pre program Post program Body weight • 70.29 ± 14.2 kg • 70.52 ± 13.8 kg P=0.281 Results Pre program Post program Average FU duration • 3 – 15 weeks • 8 ± 3 weeks • 5 – 26 weeks • 14 ± 4 weeks p<0.001 Results Pre program Post program VO2 max • 17.85 ± 5.04 L/kg/min • 19.91 ± 3.40 L/kg/min p=0.093 Results Minnesota Living with HFQ Pre program Post program • 2 - 88 • 33.7 ± 10.31 • 2 – 59 • 19.4 ± 10.9 p<0.001 outcome of the patient Results 80 Consequences of the patients in their future care 60 40 Percent 20 0 continue fu inactive/long fu referred back to AC outcome of the patient heart transplant dead Discussion • As evidenced by this project telephone patients on a weekly basis to monitor their status, guide by a standardized protocol and by asking the same questions with each phone call, Patient educators can quickly detect improvement or deterioration. If the condition is worsening, early intervention can be implemented, often avoiding acute exacerbation and hospital admission. Lessons Learned • Development of the shifting to Community Oriented Care HF program was challenging, • Outpatients enrolled in this program greatly benefit from a decrease in recidivism and from improved functional status, physical endurance, and quality of life Limitations • This study was a non-randomized trial, the participants willing to join this program were self motivated that may overestimate the benefit of this program • It was a relatively small study, larger studies involving more patients are needed to confirm the efficacy and to identify which patient groups will benefit the most from this program Conclusion • As evidenced by this project, patients could be empowered to participate in their own care at home and in the community by adequate education and continuous tele-care which could promote healthy behavior as reflected by the high adherence to drugs and dietary regimen and better symptoms control among our clients.