1. Paradigm Shift – Inpatient towards outpatient and community oriented care on heart failure patients Prepared by Camille K T HO

2. Acknowledgement Dr. S C LEUNG (HCE)Dr. S C LEUNG (HCE) Dr. W H CHOW (COS)Dr. W H CHOW (COS) Dr. E CHAU (SMO)Dr. E CHAU (SMO) Ms C L LEE (DOM)Ms C L LEE (DOM) Ms W HUNG (GMN)Ms W HUNG (GMN) Prof. F WongProf. F Wong All members of the team (CMU)All members of the team (CMU)

3. Introduction Heart failure is a common and costly cause of admissions to hospitals each yearHeart failure is a common and costly cause of admissions to hospitals each year The cost of heart failure is increasing because the population is living longerThe cost of heart failure is increasing because the population is living longer (Stewart et al 2002)

4. Introduction Patients with congestive heart failure =$$$ Unplanned admissions Unplanned follow ups Reduce quality of life Significant morbidity

5. In Hong Kong, the overall incidence was 0.7 per 1,000 population admitted to hospitals due to heart failure, with plenty of readmissions and unplanned follow up. These preventable negative factors include noncompliance with medications or diet, inadequate discharge planning or follow up, and failure to seek medical attention promptly when symptoms recur. (Leung et al 2004) (Leung et al 2004)

6. Purposes of the program Empowering the patients in self-management of their heart failure symptomsEmpowering the patients in self-management of their heart failure symptoms Improve their quality of lifeImprove their quality of life Promote their care in the communityPromote their care in the community Reduce the unplanned readmissions and follow upReduce the unplanned readmissions and follow up

7. Expected Results ↑↑ Treatment compliance↑↑ Treatment compliance Better symptoms controlBetter symptoms control Increase exercise capacityIncrease exercise capacity Improve NYHAFCImprove NYHAFC ↓↓ frequency of unplanned follow up↓↓ frequency of unplanned follow up ↓↓ unplanned readmission↓↓ unplanned readmission Transfer back to general cardiac careTransfer back to general cardiac care

8. Methods Participants’ selection criteria >18>18 M/FM/F NYHAFC 2-4NYHAFC 2-4 CAN READ AND WRITE CHINESECAN READ AND WRITE CHINESE PRIMARY DIAGNOSIS OF HEART FAILUREPRIMARY DIAGNOSIS OF HEART FAILURE REGULAR FU in GH Heart Failure ClinicREGULAR FU in GH Heart Failure Clinic

9. Methods Flow for Heart Failure Clients Home-based Monitoring Program Initial assessment by SMO/Patient Educator (PE) of CMU, GH, in the HFC for suitable participants unsuitable candidates suitable candidates Baseline assessment of patient’s condition obtained PE (Nurse) conduct patient education program for client enrolled in the home-based monitoring program (Refer to appropriate allied health care professionals prn) Patient home–based Monitoring program with Tele-nursing by PE continue follow up in the HFC

10. Methods 1.Assessment protocol Physical examinationsPhysical examinations Daily body weightDaily body weight Daily fluid balanceDaily fluid balance Drug complianceDrug compliance Dietary complianceDietary compliance Exercise toleranceExercise tolerance Unwanted habitsUnwanted habits Quality of life assessmentQuality of life assessment

11. Methods 2.Apparatus and Measuring Instruments Blood pressure monitoring deviceBlood pressure monitoring device Logbook with fluid balance chartsLogbook with fluid balance charts Quality of life assessment testQuality of life assessment test Weight ScalesWeight Scales ± Cardiopulmonary exercise test± Cardiopulmonary exercise test

12. Data analysis of the self-management program Intake and Output balanceIntake and Output balance Symptoms controlSymptoms control Exercise capacityExercise capacity Behavior modificationBehavior modification Drug complianceDrug compliance Dietary complianceDietary compliance NYHAFC statusNYHAFC status The frequency of unplanned FU / hospitalizationThe frequency of unplanned FU / hospitalization The length of follow up periodThe length of follow up period

13. Results Patient Population From March 2004 to September 2004From March 2004 to September 2004 31 patients within the selection criteria were recruited at convenience sampling31 patients within the selection criteria were recruited at convenience sampling AgeAge 20 – 6520 – 65 Mean age 47.3 ± 10.9Mean age 47.3 ± 10.9 SexSex Male 26Male 26 Female 5Female 5

14. Results Marital status Single 7Single 7 Married 20Married 20 Divorce 1Divorce 1

15. Results Etiology of heart failure were:Etiology of heart failure were: Ischaemic cardiomyopathy = 12.9%Ischaemic cardiomyopathy = 12.9% Dilated cardiomyopathy = 70.9%Dilated cardiomyopathy = 70.9% Acquired valvular disease = 12.9%Acquired valvular disease = 12.9% Others = 3.3%Others = 3.3%

16. Results Pre program Mean ejection fraction = 34.54 ± 10.8% NYHAFC Class I 0%Class I 0% Class II 16.1%Class II 16.1% Class III 71%Class III 71% Class IV 12.9%Class IV 12.9% Post program = 42.05 ± 11.8% p=0.003 6.9% 79.3% 13.7% 0% p<0.001

17. Results Pre program Body weight 70.29 ± 14.2 kg70.29 ± 14.2 kg Post program 70.52 ± 13.8 kg P=0.281

18. Results Pre program Average FU duration 3 – 15 weeks3 – 15 weeks 8 ± 3 weeks8 ± 3 weeks Post program 5 – 26 weeks 14 ± 4 weeks p<0.001

19. Results Pre program VO2 max 17.85 ± 5.04 L/kg/min17.85 ± 5.04 L/kg/min Post program 19.91 ± 3.40 L/kg/min p=0.093

20. Results Minnesota Living with HFQ Pre program 2 - 882 - 88 33.7 ± 10.3133.7 ± 10.31 Post program 2 – 59 19.4 ± 10.9 p<0.001

21. Results Consequences of the patients in their future care

22. Discussion As evidenced by this project telephone patients on a weekly basis to monitor their status, guide by a standardized protocol and by asking the same questions with each phone call, Patient educators can quickly detect improvement or deterioration. If the condition is worsening, early intervention can be implemented, often avoiding acute exacerbation and hospital admission.As evidenced by this project telephone patients on a weekly basis to monitor their status, guide by a standardized protocol and by asking the same questions with each phone call, Patient educators can quickly detect improvement or deterioration. If the condition is worsening, early intervention can be implemented, often avoiding acute exacerbation and hospital admission.

23. Lessons Learned Development of the shifting to Community Oriented Care HF program was challenging,Development of the shifting to Community Oriented Care HF program was challenging, Outpatients enrolled in this program greatly benefit from a decrease in recidivism and from improved functional status, physical endurance, and quality of lifeOutpatients enrolled in this program greatly benefit from a decrease in recidivism and from improved functional status, physical endurance, and quality of life

24. Limitations This study was a non-randomized trial, the participants willing to join this program were self motivated that may overestimate the benefit of this programThis study was a non-randomized trial, the participants willing to join this program were self motivated that may overestimate the benefit of this program It was a relatively small study, larger studies involving more patients are needed to confirm the efficacy and to identify which patient groups will benefit the most from this programIt was a relatively small study, larger studies involving more patients are needed to confirm the efficacy and to identify which patient groups will benefit the most from this program

25. Conclusion As evidenced by this project, patients could be empowered to participate in their own care at home and in the community by adequate education and continuous tele-care which could promote healthy behavior as reflected by the high adherence to drugs and dietary regimen and better symptoms control among our clients.As evidenced by this project, patients could be empowered to participate in their own care at home and in the community by adequate education and continuous tele-care which could promote healthy behavior as reflected by the high adherence to drugs and dietary regimen and better symptoms control among our clients.