Clinical trial NCT06937827: Transitions of Care Clinic (TOCC)
Official title: Impact of Multidisciplinary Transitions of Care Clinic on Readmission Rates for Patients With Heart Failure With Preserved Ejection Fraction at a University Medical Center
Study type: INTERVENTIONAL
Overall status: NOT_YET_RECRUITING
Phase: NA
Conditions: Heart Failure With Preserved Ejection Fraction
Keywords: Discharge plans
heart failure with preserved ejection fraction
Readmissions
transition of care
Lead sponsor: Hackensack Meridian Health
Sponsor class: OTHER
Collaborators: name: New Jersey Health Foundation
First posted: 2025-04-22
Enrollment: 150
Sex: ALL
Minimum age (years): 18
Maximum age (years): 90
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NON_RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Active cohort will be compared to historical controls
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: The transition period from hospital to home is a time of heightened risk for patients to experience adverse events, medication errors, and readmission to the hospital. Patients at the highest risk include older adults and patients with low health literacy, socioeconomic disadvantages, and/or multiple comorbidities. This project proposes to expand the existing Transitions of Care Clinic (TOCC) which was recently introduced in our institution in 2024, to bridge the gap in care between hospital discharge to home and connect discharged patients to their outpatient providers with a focus on patients with heart failure (HF).

The existing TOCC, a multidisciplinary team composed of a pharmacist and a nurse practitioner, seeks to improve the services that are currently being provided to patients and enhance the transitions of care process by providing patients with education, tools, and resources to help manage their chronic disease. With this study, we propose to expand TOCC by offering extensive education to patients via iPad videos and providing them with HF tool kits prior to their discharge. We will also assist with scheduling follow appointments with their outpatient providers and follow up with patients after the appointment takes place to re-evaluate their needs and reinforce self management of heart failure.

By targeting patients being treated for acute exacerbation of heart failure with preserved ejection fraction (HFpEF), this study aims to facilitate the transition of care, reduce hospital readmissions and improve patients' quality of life and satisfaction. Patients with HFpEF represent a majority of the HF patients that are readmitted at OUMC. HFpEF patients have fewer guideline recommended treatments and represent a vulnerable patient population. The HF tool kits will provide these patients with the essential tools, resources, and log sheets for self-management such as monitoring daily weights, monitoring blood pressure and heart rate. Patients provided with a kit will receive an initial phone call from TOCC within 1 to 3 days of discharge and a second phone call within 21-24-days post discharge.


Eligibility criteria: Inclusion Criteria:

* Adults ages 18 to 90 years old discharged from Ocean University Medical Center (OUMC)
* Inpatient admission for heart failure with preserved ejection fraction (HFpEF) exacerbation
* Patient discharged home

Exclusion Criteria:

* Refuse to participate in TOCC phone calls
* Discharged to a facility
* Discharged with homecare services
* Discharged on hospice services
* Hemodialysis
* Leave against medical advice (AMA)
* Pregnant
* Diagnosed with dementia
* Without medical capacity or unable to provide own consent

Primary outcomes:
measure: All-cause 30-day hospital readmission rate for heart failure
timeFrame: 30 days post discharge
Secondary outcomes:
measure: 7-Day Provider Follow-Up
timeFrame: 7 day post discharge
measure: Patient Satisfaction with Transition of Care
timeFrame: 31 to 45 days post discharge
Other outcomes:
Locations:
city: Brick
country: United States
facility: Ocean University Medical Center
state: New Jersey
Study officials:
affiliation: Hackensack Meridian Health
name: Alexandria Berns, PharmD
role: PRINCIPAL_INVESTIGATOR
References: