Mobile Integrated Health in Heart Failure

ID#: NCT04662541

Age: 18 years - 66+

Gender: All

Healthy Subjects: No

Study Phase: N/A

Recruitment Status: Recruiting

Start Date: January 04, 2021

End Date: April 30, 2023

Contact Information:
Ruth M. Masterson Creber, PhD, MSc, RN
(212) 305-5756
Brock Daniels, MD, MPH
(212) 821-0850
Summary: The purpose of this study is to compare how two different types of care after a hospitalization reduce hospital readmissions and symptom burden. The two types of care are a Transitions of Care Coordinator and Mobile Integrated Health. In the Transitions of Care Coordinator group, participants will receive a phone call from a care coordinator right after they go home following a hospitalization to check in. In the Mobile Integrated Health group, participants will be offered access to a community paramedic in case they need medical care while they are recovering at home after a hospitalization. The community paramedic will come to their home to perform an evaluation and set up a visit with an emergency physician via video conference. They may receive treatment at home or be transported to the emergency department. The investigators will be compare how well a Transitions of Care Coordinator and Mobile Integrated Health reduce readmissions to the hospital within 30 days of discharge and improve patient-reported health-related quality of life. The investigators hypothesize that participants in the Mobile Integrated Health group will have fewer readmissions to the hospital within 30 days of discharge and better health-related quality of life compared to participants in the Transitions of Care Coordinator group.

Inclusion Criteria:

- Medicare or Medicaid recipient

- Current diagnosis of HF

- Receiving inpatient care at NewYork Presbyterian or Mount Sinai Health Systems

- Live in NYC

Exclusion Criteria:

- Non-English, Spanish, Mandarin, or French speaking

- Diagnosis of dementia or psychosis

- Anticipated discharge to, or current residence in, skilled nursing facility or rehab center

- Anticipated discharge to, or currently receiving, hospice including home hospice

- Current candidate for and awaiting heart transplant

- Current left ventricular assist device (LVAD)