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:

* Women and men above 18 years
* Must have signed the "Informed Consent" document
* Must be able to understand study information
* Must live in Hjørring or Frederikshavn Kommune
* Must have mobile network
* Must be able to use IT or have a near person who can use IT
* Patients with clinical diagnosis of Heart Failure, Myocardial Infarction, Angina Pectoris, patients who have had Coronary-Artery Bypass Surgery.

Exclusion Criteria:

* Patients who, according to investigator, will not be able to participate in the study
* Lack of ability to speak and understand Danish
* Pregnancy or nursing
* Neurologic disease
* Use of wheelchair/lack of ability to walk
* Participation in other studies which can influence the outcomes of this study
B: 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
C: Inclusion Criteria:

* Documented coronary artery disease and/or acute coronary syndrome diagnosis and/or revascularization (coronary bypass graft or angioplasty) and/or valve surgery
* Work or reside in Greater Toronto Area
* Proficiency in English language
* Written approval to participate in CR by the patient's cardiac specialist or general practitioner
* Eligible for home-based CR

Exclusion Criteria:

* musculoskeletal, neuromuscular, visual, cognitive or non-dysphoric psychiatric condition, or any serious or terminal illness not otherwise specified which would preclude CR eligibility based on CR guidelines
* physician deems patient not suitable for CR at time of intake exercise stress test
* planning to leave the area prior to the anticipated end of participation
* being discharged to a long-term care facility
* participation in another clinical trial with behavioral interventions
D: Inclusion Criteria:

* Diagnosis of Chronic Heart Failure;
* low health status.

Exclusion Criteria:

* Cognitive/psychiatric impairment (inability to complete questionnaires);
* nursing home resident;
* irreversible non-cardiac medical condition likely to affect 6-month survival or ability to execute study protocol;
* prior heart transplantation.

Answer: B