Trial Summary
What is the purpose of this trial?This trial compares two methods of post-hospital care for heart failure patients: phone check-ins by a care coordinator and home visits by paramedics with video doctor consultations. The goal is to see which method better reduces hospital readmissions and improves patient quality of life.
Do I have to stop taking my current medications for this trial?
The trial protocol does not specify whether you need to stop taking your current medications. It seems likely that you can continue your medications, but you should confirm with the trial coordinators.
What data supports the idea that Mobile Integrated Health for Heart Failure is an effective treatment?
The available research shows that Mobile Integrated Health can effectively reduce hospital readmissions for heart failure patients. For example, the MIGHTy-Heart study aims to compare the effectiveness of Mobile Integrated Health and telehealth in supporting patients after they leave the hospital. Additionally, a study on transition management services found that hospital readmission rates decreased from 17.9% to 8.0% after implementing these services, which are similar to Mobile Integrated Health. This suggests that Mobile Integrated Health can help keep heart failure patients healthier and out of the hospital.
12345What safety data exists for Mobile Integrated Health for Heart Failure?
The research indicates that Mobile Integrated Health (MIH) and related models like Community Paramedicine and Transitional Care aim to improve care coordination and reduce hospital readmissions for heart failure patients. These models focus on continuous management and communication across care settings, which can potentially reduce adverse events associated with poor care transitions. However, specific safety data for these interventions is not detailed in the provided research, suggesting a need for further studies to evaluate their safety comprehensively.
678910Is Mobile Integrated Health a promising treatment for heart failure?
Yes, Mobile Integrated Health is a promising treatment for heart failure. It can improve patient care, reduce hospital readmissions, and fill gaps in local healthcare by using emergency medical services in new ways. This approach helps patients manage their condition better at home, which can lead to fewer hospital visits and better overall health outcomes.
29111213Eligibility Criteria
This trial is for Medicare or Medicaid recipients with heart failure in NYC (Manhattan, Brooklyn, Queens, Bronx) who are getting out of the hospital. It's not for those who don't speak English, Spanish, Mandarin, or French; have dementia/psychosis; will go to/receive care from a nursing facility/rehab/hospice; or await a heart transplant/LVAD.Inclusion Criteria
Live in NYC
I am currently receiving care at NewYork Presbyterian or Mount Sinai.
I receive Medicare or Medicaid benefits.
+1 more
Exclusion Criteria
I will be, or am currently living in, a skilled nursing facility or rehab center.
Current left ventricular assist device (LVAD)
I am on the waiting list for a heart transplant.
+3 more
Participant Groups
The study compares two post-hospitalization care methods: phone check-ins by a Transitions of Care Coordinator and at-home medical services by Mobile Integrated Health with community paramedics and video calls with doctors. The goal is to see which method better reduces hospital readmissions and improves life quality within 30 days after discharge.
2Treatment groups
Experimental Treatment
Active Control
Group I: Mobile Integrated Health (MIH)Experimental Treatment1 Intervention
Patients with urgent medical needs are seen and treated in the home by trained community paramedics. The community paramedics perform a standardized assessment, including a physical examination, vital signs, home safety evaluation, and medication reconciliation. During the MIH encounter, the emergency medicine physician at each site is contacted via telemedicine. Physicians can access clinical notes, discharge summaries, and medication lists via the institutional EHR. Adjustments to outpatient medications can be e-prescribed and follow-up appointments can be scheduled with primary care clinicians.
Group II: Transitions of care coordinator (TOCC)Active Control1 Intervention
Patients receive a follow-up phone calls for a nurse coordinator within 48-72 hours of hospital discharge. Phone calls include clinical/social needs assessment with escalation to primary care team, emergency care, or social work as needed; patient education; and reminder about follow-up appointments.
Mobile Integrated Health is already approved in United States for the following indications:
🇺🇸 Approved in United States as Mobile Integrated Health for:
- Congestive Heart Failure
- Chronic Obstructive Pulmonary Disease (COPD)
- Pneumonia
- Cellulitis
- Dehydration
- COVID-19
- Behavioral Health Conditions
Find a Clinic Near You
Research Locations NearbySelect from list below to view details:
New York Presbyterian/Weill Cornell MedicineNew York, NY
Mount Sinai Health SystemNew York, NY
Columbia University Irving Medical CenterNew York, NY
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Who Is Running the Clinical Trial?
Columbia UniversityLead Sponsor
Weill Medical College of Cornell UniversityLead Sponsor
Patient-Centered Outcomes Research InstituteCollaborator
References
Impact of an integrated transition management program in primary care on hospital readmissions. [2016]Poorly executed transitions in care from hospital to home are associated with increased vulnerability to adverse medication events and hospital readmissions, and also excess healthcare costs. Efforts to improve care coordination on hospital discharge have been shown to reduce hospital readmission rates but often rely on interventions that are not fully integrated within the primary care setting. The Patient Centered Medical Home (PCMH) model, whose core principles include care coordination in the posthospital setting, is an approach that addresses transitions in care in a more integrated fashion. We examined the impact of multicomponent transition management (TM) services on hospital readmission rates and time to hospital readmission among 118 patients enrolled in a TM program that is part of Care By Design, the University of Utah Community Clinics' version of the PCMH. We conducted a retrospective analysis comparing outcomes for patients before receiving TM services with outcomes for the same patients after receiving TM services. The all-cause 30-day hospital readmission rate decreased from 17.9% to 8.0%, and the mean time to hospital readmission within 180 days was delayed from 95 to 115 days. These findings support the effectiveness of TM activities integrated within the primary care setting.
Using Mobile Integrated Health and telehealth to support transitions of care among patients with heart failure (MIGHTy-Heart): protocol for a pragmatic randomised controlled trial. [2022]Label="INTRODUCTION">Nearly one-quarter of patients discharged from the hospital with heart failure (HF) are readmitted within 30 days, placing a significant burden on patients, families and health systems. The objective of the 'Using Mobile Integrated Health and Telehealth to support transitions of care among patients with Heart failure' (MIGHTy-Heart) study is to compare the effectiveness of two postdischarge interventions on healthcare utilisation, patient-reported outcomes and healthcare quality among patients with HF.
An Innovative Approach to Health Care Delivery for Patients with Chronic Conditions. [2018]Although the health care reform movement has brought about positive changes, lingering inefficiencies and communication gaps continue to hamper system-wide progress toward achieving the overarching goal-higher quality health care and improved population health outcomes at a lower cost. The multiple interrelated barriers to improvement are most evident in care for the population of patients with multiple chronic conditions. During transitions of care, the lack of integration among various silos and inadequate communication among providers cause delays in delivering appropriate health care services to these vulnerable patients and their caregivers, diminishing positive health outcomes and driving costs ever higher. Long-entrenched acute care-focused treatment and reimbursement paradigms hamper more effective deployment of existing resources to improve the ongoing care of these patients. New models for care coordination during transitions, longitudinal high-risk care management, and unplanned acute episodic care have been conceived and piloted with promising results. Utilizing existing resources, Mobile Integrated Healthcare is an emerging model focused on closing these care gaps by means of a round-the-clock, technologically sophisticated, physician-led interprofessional team to manage care transitions and chronic care services on-site in patients' homes or workplaces.
Exploring Transitional Care: Evidence-Based Strategies for Improving Provider Communication and Reducing Readmissions. [2020]The coordination of care as patients move from one health care setting to another is crucial to treatment, but breakdowns in the process lead to poor transitions, fragmented care, hospital readmissions, and increased costs. This article discusses evidence-based strategies for improving communication and reducing readmissions.
Implementation of a comprehensive program to improve coordination of care in an urban academic health care system. [2018]Purpose Academic healthcare systems face great challenges in coordinating services across a continuum of care that spans hospital, community providers, home and chronic care facilities. The Johns Hopkins Community Health Partnership (J-CHiP) was created to improve coordination of acute, sub-acute and ambulatory care for patients, and improve the health of high-risk patients in surrounding neighborhoods. The paper aims to discuss this issue. Design/methodology/approach J-CHiP targeted adults admitted to the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, patients discharged to participating skilled nursing facilities (SNFs), and high-risk Medicare and Medicaid patients receiving primary care in eight nearby outpatient sites. The primary drivers of the program were redesigned acute care delivery, seamless transitions of care and deployment of community care teams. Findings Acute care interventions included risk screening, multidisciplinary care planning, pharmacist-driven medication management, patient/family education, communication with next provider and care coordination protocols for common conditions. Transition interventions included post-discharge health plans, hand-offs and follow-up with primary care providers, Transition Guides, a patient access line and collaboration with SNFs. Community interventions involved forming multidisciplinary care coordination teams, integrated behavioral care and new partnerships with community-based organizations. Originality/value This paper offers a detailed description of the design and implementation of a complex program to improve care coordination for high-risk patients in an urban setting. The case studies feature findings from each intervention that promoted patient engagement, strengthened collaboration with community-based organizations and improved coordination of care.
The effect of a mobile integrated health program on health care cost and utilization. [2022]To measure the effect of a mobile integrated health community paramedicine (MIH-CP) transitional care program on hospital utilization, emergency department visits, and charges.
Heart failure management across the continuum: a communication link. [2007]Patients with heart failure often become lost in the ambulatory healthcare maze on hospital discharge. This causes fragmentation of care due to a lack of a communication link with the ambulatory setting. This article discusses a quality improvement project and addresses the use of a communication tool that helps to transition the plan of care for the heart failure patient from acute care to the ambulatory care setting. The key points focus on the continuance of the plan of care that began during hospitalization and is then extended into the ambulatory setting through care management services.
The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly. [2021]Suboptimal care transitions increases the risk of adverse events resulting from poor care coordination among providers and healthcare facilities. The National Transition of Care Coalition recommends shifting the discharge paradigm from discharge from the hospital, to transfer with continuous management. The patient centered medical home is a promising model, which improves care coordination and may reduce hospital readmissions.
Transitional Care to Reduce Heart Failure Readmission Rates in South East Asia. [2020]Heart failure (HF) is an emerging public health problem due to increasing hospitalisations, readmissions and direct healthcare costs. Transitional care (TC) aims to improve multidisciplinary care coordination in HF and provides a streamlined strategy to ensure discharge success. This article reviews the different TC models and interventions in HF, and compares their strengths, weaknesses and efficacies. Notably, a nurse-led TC model under the direct administration of a dedicated multidisciplinary team appears to be the superior model of care. The emerging use of remote technology to track patient progress adds value, as human resources are scarce. Several knowledge gaps are highlighted in this article. The authors share their local institutional TC experience and discuss its early impact on HF care.
Cost-Effectiveness of Transitional Care Services After Hospitalization With Heart Failure. [2020]Patients with heart failure (HF) discharged from the hospital are at high risk for death and rehospitalization. Transitional care service interventions attempt to mitigate these risks.
Factors Associated With Successful Enrollment in a Community Paramedicine Program for Heart Failure. [2023]Introduction Participation in community paramedicine (CP) programs, sometimes referred to as Mobile Integrated Healthcare (MIH), may improve patient-centered outcomes and reduce hospital readmissions. The objective of this study was to correlate patient and system-specific factors with successful enrollment in a CP program for heart failure. Methods We conducted a retrospective review of patients enrolled in a CP program after hospitalization for a heart failure-related diagnosis. All patients greater than 18 years of age referred to the CP program with a heart-failure-related diagnosis were included. Factors including age, sex, hospital length of stay, enrollment method, concurrent use of transitional care services, care team, and service line referral were collected. The primary outcome was successful enrollment which led to an initial home visit. Chi-square and t-tests were performed to determine if the outcome differed between cohorts. Results A total of 908 patients met the inclusion criteria, and 677 (74.7%) received home visits. Increased participation was noted in patients enrolled in person (81.1% vs. 66%, p
Reducing Hospital Admissions for Patients with Heart Failure by Implementing the Chronic Care Management Framework: A Cost, Quality and Satisfaction Improvement Project. [2022]To reduce the rate of hospital admissions, and increase the perception of coordinated care for patients with heart failure and associated co-morbidities through improvement of interdisciplinary communication.
Mobile Integrated Health Care and Community Paramedicine: An Emerging Emergency Medical Services Concept. [2018]Mobile integrated health care and community paramedicine are models of health care delivery that use emergency medical services (EMS) personnel to fill gaps in local health care infrastructure. Community paramedics may perform in an expanded role and require additional training in the management of chronic disease, communication skills, and cultural sensitivity, whereas other models use all levels of EMS personnel without additional training. Currently, there are few studies of the efficacy, safety, and cost-effectiveness of mobile integrated health care and community paramedicine programs. Observations from existing program data suggest that these systems may prevent congestive heart failure readmissions, reduce EMS frequent-user transports, and reduce emergency department visits. Additional studies are needed to support the clinical and economic benefit of mobile integrated health care and community paramedicine.