Reducing Readmission for Frail Elderly Patients With Decompensated Heart Failure

A Prospective Randomized Pilot Trial to Reduce Readmission for Frail Elderly Patients With Acute Decompensated Heart Failure

A randomized study designed to determine whether telephone based interventions can prevent return hospital visits for elderly and frail patients with acute symptoms of heart failure. Specifically, the intervention will improve patients ability to monitor and address self care of heart failure at home.

Acute decompensated heart failure (ADHF) is a common illness in Canadian emergency departments (ED). The frail subset of elderly patients with ADHF is challenging to treat, use a large proportion of available resources, and are at higher risk for complications, including readmission to hospital after discharge. The investigators believe that by improving access to follow-up, optimizing self-care, and addressing the various cognitive and physical limitations of frailty, it will be possible to improve quality of life and reduce readmission rates for frail patients with ADHF.

Inclusion Criteria:

• Patients who presented to the ED and who are being discharged with a primary or secondary diagnosis of ADHF
• Age ≥ 65
• Frailty, defined as a FRAIL score >=3/5 or Clinical Frailty Scale (CFS) score >=5/9
• Informed consent provided by the patient or proxy

Exclusion Criteria:

• Significant dementia or active delirium
• Severe frailty, defined as a CFS score >=8/9
• Prohibitive language barrier
• Primary address outside of Quebec
• Patient deemed to be palliative or moribund by treating team