Regional Collaboration for Heart Failure Patients Certified as Needing Support or Care in Long-Term Care Insurance System.
Circ J
; 2024 Aug 24.
Article
in En
| MEDLINE
| ID: mdl-39183036
ABSTRACT
BACKGROUND:
Heart failure (HF) patients with complex care needs often experience exacerbations during the transitional phase as care providers and settings change. Regional collaboration aims to ensure continuity of care; however, its impact on vulnerable patients certified as needing support or care under the Japanese long-term care insurance (LTCI) system remains unclear. METHODS ANDRESULTS:
We implemented a regional collaborative program for HF patients involving 3 pillars of transitional care with general practitioners and nursing care facilities (1) standardized health monitoring using a patient diary and identification of exacerbation warning signs; (2) standardized information sharing among care providers; and (3) standardized HF management manuals. We evaluated outcomes within 1 year of discharge for patients hospitalized with HF and referred to other facilities for outpatient follow-up in 2017-2018 before program implementation (n=110) and in 2019-2020 after implementation (n=126). Patients with LTCI frequently received non-cardiologist follow up and care services and had a higher risk of all-cause mortality and HF readmission compared with those without LTCI (P<0.05). Program implementation was significantly associated with a greater reduction in HF readmissions among patients with LTCI compared with those without (P<0.05 for interaction), although mortality rates remained unchanged.CONCLUSIONS:
A regional collaborative program significantly reduces HF readmissions in HF patients with LTCI who are at high risk of worsening HF.
Full text:
1
Collection:
01-internacional
Database:
MEDLINE
Language:
En
Journal:
Cir. j
/
Circ J
/
Circulation journal
Journal subject:
ANGIOLOGIA
/
CARDIOLOGIA
Year:
2024
Type:
Article