Formulation and application of the “hospital-to-home + online-to-offline” treatment scheme in caring for and supporting vulnerable patients with chronic heart failure

Abstract

BACKGROUND:

Chronic heart failure (CHF) is the terminal stage of cardiovascular disease.

OBJECTIVE:

In this study, the “hospital-to-home $+$ online-to-offline” (H2H $+$ O2O) care scheme was implemented for patients with CHF during vulnerable periods, and its effect was evaluated.

METHODS:

Patients with CHF in the cardiovascular department of a Class III/Grade A hospital in Jiangxi Province from January to December 2020 were selected using a convenience sampling method and randomly divided into a control and intervention group ( $n=$ 100 each). The patients in the control group received routine in-hospital treatment and out-of-hospital follow-up, while in the intervention group, a multi-disciplinary cooperation team with CHF specialist nurses evaluated and stratified the patients before discharge and formulated individualized prescriptions and care plans. Based on the “Health & Happiness” chronic disease follow-up application designed for this study, the specialist nurses provided patients with one-to-one guidance. After three months, the cardiac function, heart failure knowledge, self-care behavior, and re-hospitalization rate of the patients were compared between the two groups. Cardiac function was evaluated by the serum B-type natriuretic peptide (BNP), the left ventricular ejection fraction (LVEF), and a six-minute walking test (6MWT). Heart failure knowledge and self-care behavior was assessed using specific questionaries.

RESULTS:

The level of cardiac function in the intervention group was significantly higher than that in the control group, and the difference was statistically significant ( $P<$ 0.001). The mastery of heart failure knowledge and self-care behavior in the intervention group were significantly higher than those in the control group, and the differences were statistically significant ( $P<$ 0.05). The re-hospitalization rate due to CHF in the intervention group was 21.0%, which was lower than that in the control group (35.0%), and the difference was statistically significant ( $P<$ 0.05).

CONCLUSION:

The H2H $+$ O2O care scheme can be used for the transition of vulnerable patients with CHF from the hospital to family care to improve the patients’ level of cardiac function, elevate their knowledge level and self-care abilities, and improve their overall health outcomes.

Keywords

Chronic heart failure vulnerable period hospital-family online and offline

1. Introduction

Chronic heart failure (CHF) is the terminal stage of cardiovascular disease [1]. Existing studies showed that the mortality and re-hospitalization rate due to heart failure among patients with CHF may be as high as 15% and 30%, respectively, within three months after discharge. Clinically, the high incidence stage of early cardiovascular events after discharge is known as “the vulnerable period of heart failure” [2, 3]. The main reasons for re-hospitalization are persistent hemodynamic congestion and hemodynamic instability at the time of discharge.

The current approach to CHF in terms of prevention and treatment involves a larger focus on in-hospital than out-of-hospital care [4, 5]. The traditional care model is not conducive to the rehabilitation of CHF patients, and high mortality or re-hospitalization rate place a heavy burden on families and society. The “hospital-to-home $+$ online-to-offline” (H2H $+$ O2O) treatment approach is a continuous support service that is provided to patients from the hospital to the home, both online and offline [6]; it can improve patients’ self-management ability and reduce their re-hospitalization rate. “Health & Happiness” chronic disease management application platform is developed by the research group. Initially, the platform was created only to obtain the results of a satisfactory investigation about the outpatient. Later, the follow-up modules were combined into the platform to realize telemedicine follow-up, and it is integrated with the clinical healthcare system, so patients can query medical examination reports during hospitalization. The points and prize system is a section of the application, which is mainly used to improve patients’ enthusiasm for self-monitoring symptoms and signs after discharge. When the points are reached, patients can redeem corresponding cardiac function tests without other conflicts of interest.

Using a “Health & Happiness” chronic disease management application platform, the present study develops a care support scheme based on the H2H $+$ O2O approach for patients with CHF during the vulnerable period, the clinical application of which achieves good results.

2. Subjects and research methods

2.1 Study participants

A total of 200 patients with CHF in the cardiovascular department of a Class III/Grade A hospital in Jiangxi Province from January to December 2020 were selected as the study participants and randomly divided into an intervention and control group ( $n=$ 100 each) using the random number table method. The inclusion criteria were as follows: (1) patients who met the diagnostic criteria of CHF with a cardiac function grade of II–IV based on the New York Heart Association (NYHA) guidelines; (2) patients who were able to use a smartphone themselves or with the assistance of their family; (3) patients aged $\geqslant$ 18 years; and (4) patients who were informed about the study aims and provided a signed consent form to acknowledge their voluntary participation in this study. The exclusion criteria were as follows: (1) patients with respiratory system diseases, malignant tumors, liver and kidney failure, and other serious diseases; and (2) patients with mental and cognitive dysfunction and an inability to self-manage. All patients signed informed consent before the study. There were no deaths or voluntary withdrawals during the study.

2.2 Intervention methods

2.2.1 Control group

The patients in the control group received routine treatment and nursing as well as follow-up for heart failure according to the internal medicine-cardiovascular department of the hospital. At the time of discharge, the specialist nurse distributed a health education manual to the patients to promote education. A telephone follow-up was conducted three months after discharge; consultation was provided, and the patients’ questions were answered to mitigate any doubts they may have had.

2.2.2 Intervention group

For the intervention group, a multi-disciplinary cooperation team with CHF specialist nurses evaluated and stratified the patients before discharge and formulated individualized prescriptions and care plans. Specialist nurses stratified patients based on their diagnosis of heart function. Using the Health & Happiness chronic disease follow-up platform, the specialist nurses provided patients with individualized guidance and a three-month H2H $+$ O2O care model for CHF support and intervention.

2.2.2.1 Establishing a multidisciplinary management team with members who performed their respective duties

A multidisciplinary H2H $+$ O2O care support team was established for the patients with CHF in the vulnerable period, including one chief physician from the internal medicine-cardiovascular department, one director from the nursing department, and one head nurse from the internal medicine-cardiovascular department; the team was responsible for the formulation and supervision of the plan. A total of 13 individuals, including specialist nurses and doctors, clinical pharmacists, nutritionists, cardiac rehabilitators, psychologists, information personnel, and medical social workers, were responsible for the implementation of the plan, data collection, and feedback. Each team member had clear responsibilities (Supplementary Table 1).

2.2.2.2 Specific intervention plan

(1) The specialist nurses assisted patients and their families in downloading the Health & Happiness application within three days after admission and guided them in its standardized use. During hospitalization, the specialist nurses and patients jointly formulated self-care-ability training paths and carried out multi-dimensional individualized health education in different areas, such as nutrition, sign monitoring, and medication [7].

(2) One day before each patient was discharged, a specialist nurse established an electronic health management file for them and conducted an individualized discharge evaluation. This primarily included an evaluation of the patient’s self-care ability, weakness, nutrition, and other domains, such as psychological and social support, and an evaluation of the care ability and care burden of the patient’s primary caregivers. For elderly patients who lived alone, had been repeatedly hospitalized, and had low self-care abilities, the “flip discharge” approach was adopted to accurately identify their specific needs, thereby completing a smooth transition from hospital to family care [8]. Before the patients were discharged from the hospital, files were established for them that included links with community services and health centers in the relevant jurisdictions, and medical social workers visited the patients’ communities and families to assess their resources and home environment. Based on each patient’s existing voluntary support, a “CHF care package” that included a scale, measuring cup, and separate medicine box was provided. Target values, such as dry body mass, heart rate, and blood pressure, were dynamically formulated for patients to create individualized prescriptions.

(3) The follow-up plan was developed as follows: (i) Following discharge from the hospital, the patients could be automatically included in the follow-up system to establish a CHF management platform and jointly develop a “capacity control diary” module using the hospital information and follow-up systems. The patients or their caregivers provided daily information on their body weight, urine volume, and fluid intake, and the system automatically produced an early warning if any errors, omissions, or deviations from the target value of $\pm$ 20% were detected. (ii) To develop the “symptom self-test” component, the patients or their caregivers provided daily information on their heart rate and blood pressure and any chest tightness, shortness of breath, or other clinical symptoms to help strengthen the patients’ awareness of self-symptom observation. (iii) The “medication check-in” component was developed to remind the patients to take their medication correctly, on time, and in the correct quantity. (iv) The cardiovascular specialist nurses were responsible for the patients during the vulnerable period by synchronizing their follow-up results to the medical end. The patient volume and symptoms were monitored daily, and the specialist nurses conducted individual consultations with the patients to provide guidance on recognizing early warning signs. An integrated incentive mechanism was adopted so that patients who actively punched in and answered questions daily could earn points, and the accumulated points could be exchanged for free cardiac function measurements or a CHF care package. In addition, one “heart protection little guard” was selected through public appraisal on the final day of each month to improve patients’ self-management motivation. (v) Specialists communicated with the patients, answered their questions, and helped ease their fears twice a week via the Health & Happiness application; they could also adjust the treatment plan according to the patients’ dynamic health files. For patients with a disease course $\geqslant$ 5 years who had experienced more than two complications, specialist medical staff carried out a door-to-door follow-up visit twice a month to formulate exercise prescriptions and improve the patients’ self-management ability regarding chronic disease.

2.3 Evaluation indexes

2.3.1 General information questionnaire

A general information questionnaire was designed for this study and included information about the patients’ age, gender, education level, marital status, residential status, main caregiver, NYHA cardiac function grade, disease course, and body mass index (BMI).

2.3.2 Re-hospitalization rate within three months after discharge

The re-hospitalization rate reflected the proportion of patients with all-cause re-hospitalization due to disease recurrence, complications, or other reasons within three months after discharge [9]. The re-hospitalization rate of the patients during the vulnerable period within three months after discharge was calculated as follows: the number of patients with all-cause re-hospitalization within three months after discharge in the two groups/the total number of patients observed in the two groups $\times$ 100%.

2.3.3 Cardiac function indexes

Cardiac function was evaluated by the serum B-type natriuretic peptide (BNP), the left ventricular ejection fraction (LVEF), and a six-minute walking test (6MWT). A higher serum BNP level and a lower LVEF reflected poorer cardiac function.

2.3.4 The heart failure knowledge questionnaire of the patients with chronic heart failure

The Chinese version of the Atlanta Heart Failure Knowledge Test-V2 (AHFKT-V2), translated by Qian et al. [10], was adopted in the current study. It included five dimensions and 30 topics related to heart failure pathology, nutrition, behavior, symptom management, and medication, 24 single-answer questions, and 6 right-and-wrong questions. One point was given for a correct answer, and no points were given for incorrect answers. The total score ranged from 0 to 30 points, and a higher score reflected a higher level of knowledge. In the present study, the scale’s total Cronbach’s $\alpha$ coefficient was 0.863.

2.3.5 The self-care behavior of the patients with chronic heart failure

The Chinese version of the Self-Care of Heart Failure Index (SCHFI), translated and revised by Chen et al. [11], was adopted in the present study. It included three dimensions, i.e., self-care maintenance (10 items), self-care management (6 items), and self-care confidence (6 items). A Likert five-grade scoring method was employed for two items in self-care, and a Likert four-grade scoring method was employed for the remaining items. A higher score reflected better self-care behavior. In the present study, the scale’s total Cronbach’s $\alpha$ coefficient was 0.863.

2.4 Quality control

To ensure the implementation and evaluation quality of the scheme, before implementing it, the team members were trained using theory, skills, and workshops; the main content included CHF-related knowledge, guidelines and consensus interpretation, maintenance and use of the Health & Happiness follow-up system application, and data collection methods. Those who passed the case assessment and test could take the post after passing the examination. A three-level management system (nursing department $\to$ head nurse team $\to$ a nursing team) was implemented to control the content, frequency, and implementation of the discharge health education, online and offline follow-ups, and evaluation quality of the questionnaire. An assessment scale was created to quantify the work-completion effect, and the team members summarized and provided timely feedback about the results, optimized the scheme and strategy, and promoted ongoing nursing improvement.

2.5 Statistical analysis and sample size calculation

The sample size was calculated based on the formula for comparing the means of two samples: $n=2\times[(t\alpha/2+t\beta)\times s/\delta]^{2}$ . Based on the pre-trial results, we obtained $\delta=$ 2.75, $s=$ 8.03, $\beta=$ 0.1, and two-tailed $\alpha=$ 0.05. According to the standard table, $t\alpha/2=$ 1.960, and $t\beta=$ 1.282, and the sample size was around 90 in each group. Taking into account a 10% loss to follow-up, the final total sample size was determined to be 200, which was divided into an experimental group (100 cases) and a control group (100 cases).

The data were checked and input by two individuals for analysis and processing using the SPSS Statistics 24.0 software program. Normally distributed measurement data were expressed as the mean $\pm$ standard deviation and compared between the two groups using a $t$ -test and a rank-sum test. Count data were expressed as a percentage and a proportion (%) and compared between the two groups using a chi-square ( $X^{2}$ ) test. A $P$ -value $<$ 0.05 was considered statistically significant.

3. Results

3.1 Comparison of the general situations of the two groups

There was no significant difference between the two groups in terms of age, gender, education level, marital status, residential status, main caregivers, per capita monthly income, NYHA cardiac function grade, disease course, or BMI prior to the intervention (Table 1).

Table 1
Comparisons of general data between the two groups

Items	Control group ( $n=$ 100)	Intervention group ( $n=$ 100)	$t$ / $X^{2}$ value	$p$ -value
Age (years)	64.38 $\pm$ 11.36	63.19 $\pm$ 9.47	1.665	0.089
Gender, $n$ (%)			0.087	0.812
Male	56 (56.00)	52 (52.00)
Female	44 (44.00)	48 (48.00)
Education level, $n$ (%)			0.224	0.985
Primary school and below	9 (9.00)	11 (11.00)
Junior high school	39 (39.00)	37 (37.00)
High school	32 (32.00)	35 (35.00)
Undergraduate or above	19 (19.00)	16 (16.00)
Marital status, $n$ (%)			0.151	0.882
Married	89 (89.00)	91 (91.00)
Unmarried	11 (11.00)	9 (9.00)
Living conditions, $n$ (%)			0.174	0.633
Live alone	13 (13.00)	12 (12.00)
Non-live alone	87 (87.00)	88 (88.00)
Major caregiver, $n$ (%)			0.138	1.359
Spouse	76 (76.00)	78 (78.00)
Son or daughter	24 (24.00)	22 (22.00)
NYHA classification, $n$ (%)			0.051	0.972
II	24 (24.00)	26 (26.00)
III	54 (54.00)	50 (50.00)
IV	22 (22.00)	24 (24.00)
Course of disease, $n$ (%)			0.043	0.957
$\leqslant$ 1 year	55 (55.00)	57 (57.00)
2–4 years	27 (27.00)	24 (24.00)
$\geqslant$ 5 years	18 (18.00)	19 (19.00)

3.2 Comparison of the cardiac function between the two groups after intervention

There were significant differences in the serum BNP, LVEF, and 6MWT results between the two groups after the intervention ( $P<$ 0.001; see Table 2).

Table 2
Comparisons of cardiac function between the two groups before and after intervention

Index	Timepoints	Control group ( $n=$ 100)	Intervention group ( $n=$ 100)	$t$ -value	$p$ -value
BNP (pg/ml)	Baseline	1135.24 $\pm$ 286.64	1028.46 $\pm$ 291.05	1.75	0.553
	Follow-up	1011.05 $\pm$ 259.43	845.47 $\pm$ 317.12	$-$ 4.884	$<$ 0.001 ${}^{*}$
LVEF (%)	Baseline	32.57 $\pm$ 5.58	33.01 $\pm$ 6.49	$-$ 0.87	0.843
	Follow-up	38.21 $\pm$ 6.35	43.07 $\pm$ 6.52	$-$ 4.61	$<$ 0.001 ${}^{*}$
6MWT (m)	Baseline	245.07 $\pm$ 85.62	242.95 $\pm$ 86.37	7.48	0.572
	Follow-up	304.98 $\pm$ 88.45	324.16 $\pm$ 90.13	$-$ 5.27	$<$ 0.001 ${}^{*}$

BNP: brain natriuretic peptide; LVEF: Left Ventricular Ejection Fractions; 6MWT: 6minute walking test. Baseline: Before the intervention; Follow-up: Three months after the intervention. ${}^{*}$ : Compared with the Control group, $p<$ 0.05.

3.3 Comparison of the atlanta heart failure knowledge test-V2 scores between the two groups after intervention

There was a significant difference in the AHFKT-V2 score between the two groups after the intervention ( $P<$ 0.001; see Table 3).

Table 3
Comparisons of AHFKT-V2 scores between the two groups

Categories	Timepoints	Control group ( $n=$ 100)	Intervention group ( $n=$ 100)	$t$ -value	$p$ -value
Heart failure pathology	Baseline	1.27 $\pm$ 0.68	1.36 $\pm$ 0.79	$-$ 0.75	0.553
	Follow-up	1.65 $\pm$ 0.57	1.89 $\pm$ 0.66	$-$ 2.73	0.039 ${}^{*}$
Nutrition	Baseline	7.39 $\pm$ 1.25	7.51 $\pm$ 0.98	$-$ 1.27	0.381
	Follow-up	8.19 $\pm$ 1.01	8.87 $\pm$ 1.09	$-$ 3.18	0.008 ${}^{*}$
Behavior	Baseline	4.27 $\pm$ 0.63	3.62 $\pm$ 0.73	$-$ 1.74	0.065
	Follow-up	3.65 $\pm$ 0.78	3.89 $\pm$ 0.74	$-$ 2.85	0.041 ${}^{*}$
Symptom management	Baseline	3.57 $\pm$ 0.86	3.62 $\pm$ 0.73	$-$ 1.74	0.065
	Follow-up	3.65 $\pm$ 0.78	3.89 $\pm$ 0.74	$-$ 2.85	0.041 ${}^{*}$
Medication	Baseline	4.42 $\pm$ 1.03	4.28 $\pm$ 0.95	$-$ 0.62	0.536
	Follow-up	5.57 $\pm$ 0.98	6.15 $\pm$ 1.24	$-$ 3.69	$<$ 0.001 ${}^{*}$

AHFKT-V2: Atlanta HF Knowledge Test, Version 2. Baseline: Before the intervention; Follow-up: Three months after the intervention. ${}^{*}$ : Compared with the Control group, $p<$ 0.05.

3.4 Comparison of the self-care of heart failure index score between the two groups after intervention

There was a significant difference in the SCHFI score between the two groups after the intervention ( $P<$ 0.001; see Table 4).

Table 4
Comparison of SCHFI score between the two groups before and after intervention

Categories	Timepoints	Control group ( $n=$ 100)	Intervention group ( $n=$ 100)	$t$ -value	$p$ -value
Self-care maintenance	Baseline	40.68 $\pm$ 12.89	42.56 $\pm$ 11.07	$-$ 2.76	0.785
	Follow-up	45.73 $\pm$ 16.55	60.48 $\pm$ 15.26	$-$ 4.15	$<$ 0.001 ${}^{*}$
Self-care management	Baseline	46.62 $\pm$ 14.54	48.39 $\pm$ 13.74	$-$ 2.03	0.893
	Follow-up	51.79 $\pm$ 17.01	64.39 $\pm$ 12.98	$-$ 3.82	$<$ 0.001
Self-care confidence	Baseline	45.11 $\pm$ 10.94	44.85 $\pm$ 11.36	$-$ 2.32	0.763
	Follow-up	52.16 $\pm$ 13.54	66.72 $\pm$ 14.41	$-$ 4.09	$<$ 0.001 ${}^{*}$

Baseline: Before the intervention; Follow-up: Three months after the intervention. ${}^{*}$ : Compared with the Control group, $p<$ 0.05.

Table 5

Comparisons of re-hospitalization rate within 3 months after discharge between the two groups

	Control group ( $n=$ 100)	Intervention group ( $n=$ 100)	$t$ -value	$p$ -value
Re-hospitalization rate, $n$ (%)	32 (32.00)	21 (21.00)	5.276	0.035 ${}^{*}$

${}^{*}$ : Compared with the Control group, $p<$ 0.05.

3.5 Comparison of the re-hospitalization rate within three months after discharge between the two groups

There was a significant difference in the re-hospitalization rate within three months between the two groups ( $P<$ 0.001; see Table 5).

4. Discussion

4.1 The hospital-to-home $+$ online-to-offline treatment scheme is conducive to the transition of patients with chronic heart failure in the vulnerable period from the hospital to family caregivers and improves patients’ cardiac function

In general, the cardiac function of patients with CHF in the vulnerable period fluctuates. At this stage, the congestive state of the heart has not yet been completely corrected, the hemodynamics are unstable, and the ventricular filling pressure is increased [4, 12]. Following the reform of the hospital system, the hospital stay of patients with CHF has been shortened; 80% of patients require a transition to their families for continued rehabilitation after passing the acute risk stage in the hospital. During the vulnerable period, patients with CHF undergo a role change and may experience a lack of self-care knowledge and ability while still having significant care needs [13, 14].

In this study, the H2H $+$ O2O care support scheme was implemented for the patients in the intervention group. The results revealed that it improved their serum BNP, LVEF, and six-minute walking distance during the vulnerable period. Overall, the H2H $+$ O2O care support program is centered on vulnerable patients with CHF. It evaluates patients prior to discharge from the hospital and formulates individualized discharge plans to ensure a smooth transition from one care environment to another, ascertain that patients’ needs are met, and allow for smooth recovery throughout the vulnerable period [15]. Additionally, as a chronic disease, CHF necessitates long-term continuous medical care. The O2O integrated management system, which included specialized nurses, multidisciplinary teams, and patients in this study, can effectively establish the status of patients’ remote self-management at home, monitor their symptoms, provide early warnings if needed, provide medication supervision, and execute effective and active interaction.

4.2 The hospital-to-home $+$ online-to-offline treatment scheme significantly improves the knowledge and behavior of patients with chronic heart failure during the vulnerable period and reduces the re-hospitalization rate

Knowledge is considered an important factor for promoting self-care behavior in patients with heart failure [16, 17]. Due to the lack of knowledge related to the cause, development, treatment and management of the disease, patients with chronic heart failure show low cognitive level and low self-efficacy, which leads to the lack of self-care ability and reduces the confidence of patients in disease self-management [18, 19]. Relevant guidelines [20, 21] show that adequate awareness of self-care management in patients with CHF is crucial for effective disease management, and improving patients’ understanding of their disease is the key to developing self-care management skills.

Domestic and foreign guidelines clearly underline the need for strengthening the self-care ability of patients with CHF to effectively reduce their re-hospitalization rate [22, 23, 24, 25]. Researchers have pointed out the necessity of an increased follow-up frequency for vulnerable patients with CHF and the early formulation of a follow-up system [3, 26, 27]. In this study, the H2H $+$ O2O care and support scheme was implemented for the patients in the intervention group; the results revealed that it was able to yield improved scores within five dimensions. Furthermore, the total score of heart-failure-related knowledge and three-dimensional scores as well as the total score for the self-care behavior of the intervention group were significantly higher than those of the control group, and the re-hospitalization rate was lower.

During the vulnerable period, patients with CHF are more dependent on medical staff and have a stronger need for knowledge about diseases, drugs, nutrition, exercise, and psychology. The H2H $+$ O2O approach can improve decision-making efficiency and help in formulating individual care plans through multidisciplinary team cooperation. Team members can discuss and subsequently decide on a treatment and nursing plan by applying their respective strengths. In this study, patient compliance was ensured through online and offline question-and-answer interactions, the provision of popular science lectures, and the formulation of a reasonable and effective incentive mechanism. Compared with the traditional follow-up mode, this approach can deliver higher-quality remote service and guidance, actively integrate medical resources, improve patients’ self-care abilities, and reduce the re-hospitalization rate.

4.3 Strengths and limitations

The advantage of this study is that it explores a care and support scheme for vulnerable patients with CHF, by which can improve their overall health outcomes. However, this study had some limitations. The sample size was not large enough and this study is of a single center study. We will conduct a multicenter study enrolling more subjects in the future.

5. Conclusion

The care and support scheme for vulnerable patients with CHF that was created based on the H2H $+$ O2O care scheme improved the patients’ serum BNP and LVEF results, increased their six-minute walking distance, significantly improved their knowledge and behavior, and reduced their re-hospitalization rate. In future research, a long-term evaluation of such patients should be conducted based on the H2H $+$ O2O approach. It is hoped that this research will help promote its popularization and application in the disease management of CHF.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was funded by the 202110060 Science and Technology Plan of Jiangxi Provincial Health Commission: “Study on the impact of H2H based transitional management model on the quality of life of patients with chronic heart failure” (2022.01-2024.12).

Ethics statement

The study was conducted in accordance with the Declaration of Helsinki (as $=$ revised in 2013). The study was approved by the Ethics Committee of the Second Affiliated Hospital Of Nanchang University (No. 2019-103). Written informed consent was obtained from all participants.

Supplementary data

The supplementary files are available to download from https://dx-doi-org.web.bisu.edu.cn/10.3233/THC-220693.

Footnotes

Acknowledgments

We are particularly grateful to everyone who helped us with the article.

References

Mullens

Damman

Harjola

, et al. The use of diuretics in heart failure with congestion – a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2019; 21(2): 137-155.

Gracia

Singh

Collins

Chioncel

Pang

Butler

. The vulnerable phase of heart failure. Am J Ther. 2018; 25(4): e456-e464.

China heart failure diagnosis and treatment guidelines 2018. Chinese Journal of Heart Failure and Cardiomyopathy. 2018(04): 196-225. Chinese. https://kns-cnki-net-443.web.bisu.edu.cn/kcms/detail/detail.aspx?dbcode=CJFD&dbname=CJFDZHYX&filename=CJHF201804002&uniplatform=NZKPT&v=VleL51DGVASHvfvvRahgZuePtDqh08qUpvw6z1mW4gTDqbXyHIly405vvEEkEQI0.

Rizzi

Sarasola

Arbé

, et al. Factors associated with in-hospital mortality and adverse outcomes during the vulnerable post-discharge phase after the first episode of acute heart failure: Results of the NOVICA-2 study [published correction appears in Clin Res Cardiol. 2020 Dec 23;:]. Clin Res Cardiol. 2021; 110(7): 993-1005.

Nick

Roberts

Petersen

. Effectiveness of telemonitoring on self-care behaviors among community-dwelling adults with heart failure: A quantitative systematic review. JBI Evid Synth. 2021; 19(10): 2659-2694.

Ohta

. Emerging technologies for heart diseases. Technol Health Care. 2021; 29(5): 1047-1048.

Rouse

Albert

Butler

, et al. A comparative study of fluid management education before hospital discharge. Heart Lung. 2016; 45(1): 21-28.

Offord

Harriman

Downes

. Discharge to assess: Transforming the discharge process of frail older patients. Future Hosp J. 2017; 4(1): 30-32.

Nair

Lak

Hasan

Gunasekaran

Babar

Gopalakrishna

. Reducing all-cause 30-day hospital readmissions for patients presenting with acute heart failure exacerbations: A quality improvement initiative. Cureus. 2020; 12(3): e7420.

10.

Reilly

Higgins

Smith

, et al. Development, psychometric testing, and revision of the Atlanta Heart Failure Knowledge Test. J Cardiovasc Nurs. 2009; 24(6): 500-509.

11.

Riegel

Lee

Dickson

Carlson

. An update on the self-care of heart failure index. J Cardiovasc Nurs. 2009; 24(6): 485-497.

12.

Greene

Fonarow

Vaduganathan

Khan

Butler

Gheorghiade

. The vulnerable phase after hospitalization for heart failure. Nat Rev Cardiol. 2015; 12(4): 220-229.

13.

TMH

Menon

Hauptman

. Reconfiguring the hospital-to-home transition into an active treatment period for patients with heart failure. JAMA Cardiol. 2017; 2(5): 467-468.

14.

Heo

Moser

Lennie

, et al. Changes in heart failure symptoms are associated with changes in health-related quality of life over 12 months in patients with heart failure. J Cardiovasc Nurs. 2018; 33(5): 460-466.

15.

Rodakowski

Rocco

Ortiz

, et al. Caregiver integration during discharge planning for older adults to reduce resource use: A metaanalysis. J Am Geriatr Soc. 2017; 65(8): 1748-1755.

16.

Tawalbeh

. The effect of cardiac education on knowledge and self-care behaviors among patients with heart failure. Dimens Crit Care Nurs. 2018; 37(2): 78-86.

17.

Delgado

. Without IPv6, there is no digital transformation for healthcare. Technol Health Care. 2022; 30(2): 505-508.

18.

Heart failure self-management [EB/OL]. (2022-05-06) [2022-05-16]. http://www-uptodate-com-443.bjmu.ilibs.cn/contents/heart-failure-self-management?search=%E5%BF%83%E5%8A%9B%E8%A1%B0%E7%AB%AD%20%E8%87%AA%E6%88%91%E7%AE%A1%E7%90%86&source=Out%20of%20date%20-%20zh-Hans&selectedTitle=1∼11.

19.

Brucker-Kley

Kleinberger

Keller

Christen

Keller-Senn

Koppitz

. Identifying research gaps: A review of virtual patient education and self-management. Technol Health Care. 2021; 29(6): 1057-1069.

20.

McDonagh

Metra

Adamo

, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021; 42(36): 3599-3726.

21.

Management of Heart Failure 2019 (4th Edition) [EB/OL]. (2019-10-01) [2022-05-16]. https://guide.medlive.cn/guideline/19781.

22.

Foster

. HF app to support self-care among community dwelling adults with HF: A feasibility study. Appl Nurs Res. 2018; 44: 93-96.

23.

Liou

Chen

Hsu

Lee

Chang

. The effects of a self-care program on patients with heart failure. J Chin Med Assoc. 2015; 78(11): 648-656.

24.

Peng

Jiang

Tian

Shao

, et al. The mechanism of Panax notoginseng in the treatment of heart failure based on biological analysis. World J Tradit Chin Med. 2022; 8: 530-8.

25.

Shen

Zhu

Liang

Zhang

. Effect of moxibustion on cardiac remodeling and myocardial function in rats with exercise-induced fatigue. World J Tradit Chin Med. 2021; 7: 254-7.

26.

Ponikowski

Voors

Anker

, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016; 18(8): 891-975.

27.

Tsutsui

Ide

Ito

, et al. JCS/JHFS 2021 Guideline Focused Update on Diagnosis and Treatment of Acute and Chronic Heart Failure. J Card Fail. 2021; 27(12): 1404-1444.

Formulation and application of the “hospital-to-home + online-to-offline” treatment scheme in caring for and supporting vulnerable patients with chronic heart failure

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Subjects and research methods

2.1 Study participants

2.2 Intervention methods

2.2.1 Control group

2.2.2 Intervention group

2.2.2.1 Establishing a multidisciplinary management team with members who performed their respective duties

2.2.2.2 Specific intervention plan

2.3 Evaluation indexes

2.3.1 General information questionnaire

2.3.2 Re-hospitalization rate within three months after discharge

2.3.3 Cardiac function indexes

2.3.4 The heart failure knowledge questionnaire of the patients with chronic heart failure

2.3.5 The self-care behavior of the patients with chronic heart failure

2.4 Quality control

2.5 Statistical analysis and sample size calculation

3. Results

3.1 Comparison of the general situations of the two groups

Table 1 Comparisons of general data between the two groups

Table 2 Comparisons of cardiac function between the two groups before and after intervention

Table 3 Comparisons of AHFKT-V2 scores between the two groups

Table 4 Comparison of SCHFI score between the two groups before and after intervention

4. Discussion

4.1 The hospital-to-home + online-to-offline treatment scheme is conducive to the transition of patients with chronic heart failure in the vulnerable period from the hospital to family caregivers and improves patients’ cardiac function

4.2 The hospital-to-home + online-to-offline treatment scheme significantly improves the knowledge and behavior of patients with chronic heart failure during the vulnerable period and reduces the re-hospitalization rate

4.3 Strengths and limitations

5. Conclusion

Competing interests

Funding

Ethics statement

Supplementary data

Footnotes

Acknowledgments

References

Table 1
Comparisons of general data between the two groups

Table 2
Comparisons of cardiac function between the two groups before and after intervention

Table 3
Comparisons of AHFKT-V2 scores between the two groups

Table 4
Comparison of SCHFI score between the two groups before and after intervention

4.1 The hospital-to-home $+$ online-to-offline treatment scheme is conducive to the transition of patients with chronic heart failure in the vulnerable period from the hospital to family caregivers and improves patients’ cardiac function

4.2 The hospital-to-home $+$ online-to-offline treatment scheme significantly improves the knowledge and behavior of patients with chronic heart failure during the vulnerable period and reduces the re-hospitalization rate