Outcomes of a 4 year Interdisciplinary Heart Failure Program by Integrated Care & Discharge Service (ICDS)

Abstract Description

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Authors (including presenting author) :

Kwan C Y(1), Wan M C(1), Yung C Y(3), Po M Y(2), Chan S O(1), Lai F L(1), Cheung C K(1), Chan M W(1), Ching Y C(1), Kwan W Y(1), Yung Y C(2), Cheng P L(2), Lee J(2), Kan K C(2), Wong Y S(2), Mak P K(2), Lee KL(3), Kng C(2)

Affiliation :

(1)Integrated Care & Discharge Service (ICDS), (2)Divisions of Geriatrics, (3)Cardiology , Ruttonjee & Tang Shiu Kin Hospital (RTSKH)

Introduction :

Geriatric Heart Failure (HF) is a top cause of readmissions and referrals to ICDS team. Multidisciplinary ICDS case managers (CM) conducted geriatric assessment and patient empowerment on heart failure at post discharge home visits for 4 years by using an evidence-based program developed by cardiologists and geriatricians.

Objectives :

To support elderly HF patients with patient empowerment and specialist support post discharge using interdisciplinary protocol to reduce readmissions.

Methodology :

Elderly above 60 years eligible for ICDS with principle diagnosis of HF were recruited. Exclusion criteria included dialysis and palliative cases. CMs provide 8 weekly home visits. Intervention consisted of (a) individualized structured education for disease knowledge and early symptom management and (b) specialist support for medication adjustment, fast track clinic or planned hospitalization.

Result & Outcome :

83 (80%) of 104 patients recruited from Aug 2014 to Aug 2018 completed the program, excluding 5 death and 16 dropouts. Age ranged from 69 to 95 years, with 58% female. 71 elderly (86%) with Abbreviated Mental Test (AMT) score >6 participated in empowerment activities, whereas relatives were engaged if AMT ≤6. New York Heart Association (NYHA) severity of HF was classed as 87% class II & 13% class III. Echocardiography performed in 57% showed 45% had heart failure with preserved ejection fraction (HFpEF defined as EF 50-70%), 34% borderline (EF 41-49%) and 21% HF with reduced EF (EF 0.05), reduced unplanned HF readmissions of 1.22 versus 0.24 (P> 0.05) and reduced length of stay of 6.8 versus 1.41 (P> 0.05). Interdisciplinary post discharge support for geriatric HF patients with evidence based protocol 1, cross-specialist input and patient education can empower patients, improve quality of life and reduce unplanned readmission.