Please select the eligibility criteria that correspond to the clinical trial below.
Title: Patient-centered Care Transitions in Heart Failure: A Pragmatic Cluster
Brief Summary: Heart failure (HF) is the most common cause of hospitalization in older adults. The month after hospital discharge represents a vulnerable period, when patients are at increased risk of death and readmission to hospital. Research has shown that certain discharge-planning services can reduce death and readmissions, but these have not been widely implemented. In this study, we will group evidence-informed discharge-planning services into 'Patient-centered Care Transitions in HF' (PACT-HF), a model of care that will prepare patients for their transition from hospital to home. Through PACT-HF, patients will benefit from a comprehensive assessment of their health care needs, learn to recognize and manage symptoms of HF, and receive the information and follow-up care needed to optimize their health. We will introduce PACT-HF to 10 Ontario hospitals over a number of time periods using a stepped wedge cluster trial design. We will compare the outcomes (hierarchically ordered) of patients in hospitals with PACT-HF to those in hospitals without PACT-HF. We anticipate that patients hospitalized at the sites with PACT-HF will have fewer readmissions, emergency visits, and deaths after discharge; report a better quality of life; and feel more prepared for discharge. We also anticipate that overall, PACT-HF will reduce health system costs.


Options:
A: Inclusion Criteria:

* patients age 55 and older
* admitted to the general medicine, family medicine, cardiology, and neurology services at San Francisco General Hospital,
* able to communicate in either English, Spanish, Mandarin or Cantonese,
* attending physicians agree to the patient's participation.
* Patients must be able to demonstrate an understanding of the study's goals through a set of teach back questions included in the consent process.

Exclusion Criteria:

* transferred from an outside hospital;
* admitted for a planned hospitalization (e.g. chemotherapy, a planned surgery)
* requiring hospice, nursing home, rehab or other institutional settings (i.e. expected by the physician team to be discharged to skilled nursing facilities) - those unable to independently consent (i.e. severely cognitively impaired, delirious, deaf, or involuntarily hospitalized because of severe mental illness)
* unable to understand English, Spanish or Cantonese (as reported by medical teams or unable to complete the consent teach-back process)
* less than age 55
* aphasic
* otherwise excluded by the medical team
* participated in the pilot project of this intervention.
B: Inclusion Criteria:

* Age 18 years or older
* Index hospitalization for congestive heart failure or chronic obstructive pulmonary disease
* Access to telephone

Exclusion Criteria:

* Cognitive impairment
* Resident of a nursing home
* Does not speak English
C: Inclusion Criteria:

* In participating hospitals, all patients hospitalized with the most responsible diagnosis of Heart Failure

Exclusion Criteria:

* Patients who die during hospitalization or are transferred to another hospital
D: Inclusion Criteria:

Patients must satisfy the following criteria based on the records from the index event:

* Is currently admitted to Cooper or Lourdes hospitals (still in hospital for recruitment)
* Resides in the following zip codes: 08101 (PO zip code), 08102-08105, 08107s, 08110
* Is 19-80 years old
* Has \>=2 hospital admissions in the past 6 months (to Camden area hospitals in the Health Information Exchange )
* Has \>=2 chronic conditions

Patients must meet at least three of the following criteria based largely on the electronic medical record:

* Has \>=5 outpatient medications
* Has difficulty accessing services
* Lacks social support
* Has mental health co-morbidity
* Is actively using drugs
* Is homeless

Exclusion Criteria:

* Already subject in RCT (treatment or control)
* Deceased or discharged prior to triage or recruitment
* Uninsured
* Cognitively impaired
* Oncology patient
* Index hospitalization is for: a surgical procedure for an acute problem, complications of a progressive chronic disease with limited treatments, or mental health issue only with no co-morbid conditions

Answer: C