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Completed

NCT Number: NCT01141907

Nurse-Led Heart Failure Care Transition Intervention for African Americans: The Navigator Program

Heart failure (HF) affects over 5 million Americans with HF morbidity reaching epidemic proportions. Annual rates of new and recurrent HF events including hospitalization and mortality are higher among African Americans. In this study, the investigators are testing an interdisciplinary model for heart failure care, with focus on enhancing self management and use of telehealth, which has significant potential to improve self management and outcomes.

The main purpose of this study is to learn how to help African Americans with heart failure care for themselves at home. We hope to find out if a team including a nurse and community health navigator using a computer telehealth device can help people with heart failure stay healthier. The team will help people with heart failure to manage their medication, monitor their symptoms and weigh themselves every day after they leave the hospital. The team will also help people with heart failure learn to solve problems that may keep them from following their treatment plan.

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Key information

Conditions

Heart Failure Cardiovascular Diseases Heart Diseases

Age range

21 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Johns Hopkins Hospital

Baltimore, Maryland, 21287, United States

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

  • hospitalized with admitting diagnosis of heart failure in prior 8 weeks
  • self-identified as African American
  • community-dwelling (i.e., not in a long-term care facility)
  • residence within a predefined radius in Baltimore City
  • working telephone in their home
  • provide signed informed consent

Exclusion criteria

  • cannot speak or understand English
  • severe renal insufficiency requiring dialysis
  • acute myocardial infarction within preceding 30 days
  • receiving home care services for HF post discharge
  • legally blind or have major hearing loss
  • screen positive for cognitive impairment on the Mini-cog at baseline
  • unable to stand independently on a weight scale (limited ability to participate in HAT system)
  • weigh more than 325 pounds (exceed scale capacity)
  • serious or terminal condition such as psychosis or cancer (actively receiving chemo or radiation)
  • pregnant

Treatment and study plan

Heart Failure Self Care Support

Behavioral

The intervention is aimed at preventing HF exacerbations and hospitalizations by improving self management with the support of the Home Automated Telemonitoring (HAT) system. The intervention was delivered by a RN-community health navigator (CHN) team over three months to HF patients and their caregivers in their home and via telephone and HAT system. The intervention was initiated during the index hospitalization. The RN-CHN team collaborated with participants, caregivers, and their usual source of HF care. Intervention strategies included tracking of weight and HF symptoms to provide feedback regarding self management and plan of care, enhancing medication and symptom self management, promoting HF care follow up, and promoting communication with providers.

Usual heart failure care

Other

Participants assigned to usual care are treated by their usual source of HF care in the usual manner and in accordance with the American College of Cardiology/American Heart Association Guidelines for the management of HF. Usual care for HF patients admitted to Johns Hopkins Hospital also includes the following: 1) Referral to HF clinic if the patient has no usual source of care and 2) HF patient education booklet.

Primary outcomes

  1. Rehospitalization

    Time frame: 3 months post enrollment

    Rehospitalization with primary diagnosis of heart failure

Sponsors and collaborators

Lead sponsor

Johns Hopkins University

Other

Collaborators

  • National Institute of Nursing Research (NINR)

Registry information

Official study title

Nurse-Led Heart Failure Care Transition Intervention for African Americans

Important dates

Study start
2010
Primary completion
2011
Study completion
2011
First posted
Jun 11, 2010
Registry last updated
Feb 19, 2019

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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