Group Medical Visits in Heart Failure (MEDIC-HF)

The primary goal of this proposal is to improve the quality of care and outcomes for patients discharged with heart failure using an innovative multidisciplinary group intervention approach. Heart failure is a complex chronic illness where comprehensive patient-centered care is difficult and resource intensive. One potential solution is to use shared medical appointments (SMA), where a multi-disciplinary team of providers with expertise in nutrition, nursing, behavior and medication management join to manage heart failure. The investigators will enroll patients from Providence, Cleveland and Phoenix VA Hospitals who were within 12 weeks of discharge from a heart failure hospitalization and randomized them to receive SMA intervention or usual care. Results from this project are expected to add an innovative intervention that could improve outcomes important for both the patient and the VA: health status, hospitalizations, and mortality.

The primary goal of this research project is to improve the health status and decrease hospitalization and death for patients discharged with heart failure (HF) via education to patients, disease monitoring and medication titration through shared medical appointments (SMAs). Studies have found patient self-care behaviors in HF (e.g. medication/dietary non-compliance) and health system factors (e.g. care discoordination, limited access, lack of education to patients and caregivers) played an important role in patient's health status and hospitalization risk to the extent that 50% of the readmissions were judged to be possibly/probably preventable. To address patient and system factors based on the Chronic Care Model, redesign of care delivery, via SMA's, can be a good solution to provide patient self-management support while also performing disease monitoring and medication management in an environment of peer support. The investigators propose a randomized controlled trial to enroll patients within 12 weeks of discharge from a HF hospitalization and randomized them to receive either SMA intervention every other one-two weeks for 4 sessions versus usual care for HF. The investigators will determine, at 180 days from randomization, whether HF patients who participate in HF-SMA, as compared to patients who receive usual care: Experience better cardiac health status measured by Kansas City Cardiomyopathy Questionnaire (primary outcome), and overall health status (EQ5D, secondary outcome); Have fewer hospitalization or death and Experience improvement in intermediate outcomes: a) increase in HF Self-Care behavior, and b) decrease in plasma BNP levels. For patients who underwent HF-SMA, the investigators will also determine perceived benefits, areas in need of improvement, potential obstacles of implementation, and fidelity of the intervention across sites, by conducting (a) face-to-face interviews with patients and (b) telephone interviews with stakeholders (physicians of the patients and administrators). The sites will be Providence VA, Cleveland VA and Phoenix VA hospitals to enroll a total of 250 patients. The study duration will be 180 days for all patients from the time of randomization. The investigators will use stratified (enrollment in other programs for HF care, <2 hospitalizations last 6 months, left ventricular ejection fraction <40%), block randomization with block sizes of 4 in each site to ensure balance of the stratified variables. The team will consist of a nutritionist, nurse, health psychologist, a clinical pharmacist and/or nurse practitioner, without the presence of a physician (cardiologist will be available on call). The session will contain an assessment of patient needs, theme-based disease self-management education, patient-initiated disease management discussion, and break-out sessions of individualized medication case management. The study findings will be used in health care management and system redesign to provide better quality and patient centered care for Veterans with HF. The long-term goal is to use a multi-disciplinary team approach in a group setting to manage HF support regular physician visits, in a peer support environment, all of which, are necessary to provide patient-centered care and improve outcomes.

Participants are assigned to either usual care group or the MEDIC-HF group in parallel for the duration of the study.

Or shared medical appointments where a multidisciplinary team of providers with expertise in nutrition, nursing, behavior and medication management join to manage heart failure in addition to and in support of, the patient's regular physician visits.

Inclusion Criteria: All subjects >18 years old, within 12 weeks of discharge from a hospitalization with a principal diagnosis of heart failure able to participate in a group setting and able to sign informed consent, will be eligible for enrollment Exclusion Criteria: Unable to attend the group sessions due to either psychiatric instability (acutely suicidal, psychotic) or organic brain injury (e.g., severe dementia, encephalopathy) that precludes self-reporting on health status Discharged to hospice or long-term nursing home facilities (as opposed to short-term rehab), or patients with a code status of comfort-measures-only since the setting and goals of disease management will be very different compared to the general HF patients after discharge, who are the target of the investigators' intervention. - Recipients of heart transplant or ventricular assist devices, patients receiving intravenous inotropic infusions for heart support, women who are pregnant, and patients with end-stage liver disease or renal disease on dialysis since these conditions would preclude them from standard HF care. All women of childbearing age will have a pregnancy test before study enrollment.

Cohen LB, Parent M, Taveira TH, Dev S, Wu WC. A Description of Patient and Provider Experience and Clinical Outcomes After Heart Failure Shared Medical Appointment. J Patient Exp. 2017 Dec;4(4):169-176. doi: 10.1177/2374373517714452. Epub 2017 Jun 20.

Wu WC, Parent M, Dev S, Hearns R, Taveira TH, Cohen L, Shell-Boyd J, Jewett-Tennant J, Marshall V, Gee J, Schaub K, LaForest S, Ball S. Group medical visits after heart failure hospitalization: Study protocol for a randomized-controlled trial. Contemp Clin Trials. 2018 Aug;71:140-145. doi: 10.1016/j.cct.2018.06.015. Epub 2018 Jun 22.