The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality

• Published in: BMC health services research 2018-06, Vol.18 (1), p.508-508, Article 508
• Main Authors: Verweij, L, Jepma, P, Buurman, B M, Latour, C H M, Engelbert, R H H, Ter Riet, G, Karapinar-Çarkit, F, Daliri, S, Peters, R J G, Scholte Op Reimer, W J M
• Format: Article
• Language: English
• Subjects: Activities of daily living; Aged; Aged, 80 and over; Alcohol; Bridges; Cardiology; Cardiovascular disease; Caregivers - organization & administration; Case management; Cognitive ability; Community health care; Delirium; Disease management; Elderly patients; Female; Frailty; Geriatric Assessment - methods; Geriatrics; Health aspects; Health services; Heart diseases; Heart Diseases - nursing; Heart Diseases - rehabilitation; Hospitalization; Hospitalization - statistics & numerical data; Hospitals; House Calls - statistics & numerical data; Humans; Integrated delivery systems; Male; Malnutrition; Methods; Mortality; Netherlands; Nurses; Nursing care; Pain Management - nursing; Patient care; Patient Care Team - organization & administration; Patient Discharge - statistics & numerical data; Patient outcomes; Patient Readmission - statistics & numerical data; Patients; Pharmacists - organization & administration; Practice; Quality of Life; Rehabilitation; Risk Assessment; Risk factors; Safety management; Single-Blind Method; Statistical analysis; Study Protocol; Systematic review; Transitional care; Transitional Care - organization & administration
• ISSN: 1472-6963; 1472-6963
• DOI: 10.1186/s12913-018-3301-9

After hospitalization for cardiac disease, older patients are at high risk of readmission and death. Although geriatric conditions increase this risk, treatment of older cardiac patients is limited to the management of cardiac diseases. The aim of this study is to investigate if unplanned hospital readmission and mortality can be reduced by the Cardiac Care Bridge transitional care program (CCB program) that integrates case management, disease management and home-based cardiac rehabilitation. In a randomized trial on patient level, 500 eligible patients ≥ 70 years and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Included patients will receive a Comprehensive Geriatric Assessment (CGA) at admission. Randomization with stratified blocks will be used with pre-stratification by study site and cognitive status based on the Mini-Mental State Examination (15-23 vs ≥ 24). Patients enrolled in the intervention group will receive a CGA-based integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) before discharge and four home visits post-discharge. The CCRNs collaborate with physical therapists, who will perform home-based cardiac rehabilitation and with a pharmacist who advices the CCRNs in medication management The control group will receive care as usual. The primary outcome is the incidence of first all-cause unplanned readmission or mortality within 6 months post-randomization. Secondary outcomes at three, six and 12 months after randomization are physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden. This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care. NTR6316 . Date of registration: April 6, 2017.