Heart failure is a leading cause of hospitalization and death, with significant consequences for quality of life and health economics. Despite exisiting knowledge and clear guidelines, only a small number of heart failure patients receive follow-up care after hospital discharge, mainly due to a lack of capacity and resources.
Individualized Tailored Home Follow-up after Hospitalization for HEART Failure (IT-HEART)
The interdisciplinary»Individualized Tailored Home Follow-up after Hospitalization for HEART Failure (IT-HEART)» project aims to determine whether customized home follow-up is a cost-effective and feasible approach to monitoring multi-illness patients following hospitalization for worsening heart failure. The project includes an observational study involving 85 participants and a multi-center clinical trial (https://clinicaltrials.gov/study/NCT05447598) where approximately 200 patients from 2023 to 2025 hospitalized with worsening heart failure are randomized to current clinical practice or digital home follow-up. The intervention involves patient education, symptom monitoring, and at-home self-recording over three months, linked to selv-care plan. Data to describe the study population and evaluate the potential effects of the intervention are collected from hospital records, clinical examinations and tests, questionnaires, digital platforms, and national registers at the start of the study and after 3 and 12 months of follow-up. Qualitative in-depth interviews with patients and study personnel will also be conducted to evaluate intervention feasibility and user/patient satisfaction.
The project is led by John Munkhaugen in collaboration with post-doctoral researcher, and involves two PhD candidates.
PILOT Study: Integrated Health Services for Frail Patients with Heart Failure
In a recently conducted prospective observational study, we found that more than 6 out of 10 patients admitted with acute heart failure in clinical practice are moderately or severely frail and frequently hospitalized. The study showed a significant potential for better follow-up of this patient group. According to the national hospital plan and regional and local development plan (HSØ), frail elderly should be a focus area. NORCOR aims to ensure that the elderly in Norway are taken care of in a safe and dignified manner in the last phase of life. IHT-H is an innovation project and research project between Drammen municipality and the medical department of Drammen hospital. Sudhir Sharma, municipal chief of home services and institution, and Madli Indseth, municipal chief of health services Drammen municipality, collaborate with department head of the medical department Oscar Kristiansen and professor John Munkhaugen, head of research and development at the medical department Drammen hospital. They have jointly led the development of a model where frail elderly with heart failure are assessed at home with the aim of improving quality of life.
Further information about the study: Study Details | INTEgRated Health CARE for Patients With Frailty and Heart Failure | ClinicalTrials.gov)
The IHT-H model: AKS nurse hospital, AKS nurse in Drammen municipality, primary contact in home nursing, general practitioner, and geriatrician assess patients admitted with severe heart failure and clinical frailty scale 5 or higher at home together with relatives one to two weeks after discharge from the hospital. The team develops a comprehensive treatment plan based on a broad geriatric assessment focusing on what is important for the patient and relatives. A self-management plan is also developed based on the traffic light model with Green, Yellow, and Red zones to identify acute deteriorations early and start treatment early with the aim of less morbidity and hospitalization for the individual patient. The model is developed by IHT AHUS. The study is well underway, and we will include patients until December 2025.