A Remote Management-Centric Postdischarge Pathway for Patients Admitted to GIM with Heart Failure.

Area of Science:

• Cardiology
• Geriatrics
• Health Services Research

Background:

• Limited transition of care (TOC) programs exist specifically for heart failure (HF) patients managed within General Internal Medicine (GIM).
• A pilot TOC program was developed for HF patients discharged from GIM, integrating the remote patient management tool, Medly.

Purpose of the Study:

• To pilot a novel TOC program for GIM-discharged HF patients.
• To evaluate the feasibility and initial outcomes of a GIM-specific HF TOC program incorporating remote patient management.

Main Methods:

• A single-center, prospective, proof-of-concept study design.
• Inclusion of ten heart failure patients with a median age of 85.
• Description of patient sociodemographic and medical characteristics.
• Computation of summary statistics for clinical and workload outcomes.

Main Results:

• No heart failure-related deaths occurred within 90 days of discharge.
• No heart failure-related re-hospitalizations were recorded within 90 days of discharge.
• No emergency department (ED) visits related to heart failure occurred within 90 days of discharge.
• One unscheduled GIM clinic visit was required.

Conclusions:

• The developed post-GIM TOC pathway effectively supports heart failure patients.
• The study suggests the potential efficacy of this innovative approach in managing HF patients post-discharge.
• Further research is recommended to evaluate the scalability of this TOC program.