Expanded Transitions of Care Clinic for patients with HFpEF

Impact of Multidisciplinary Transitions of Care Clinic on Readmission Rates for Patients With Heart Failure With Preserved Ejection Fraction at a University Medical Center

This project will try an expanded Transitions of Care Clinic that provides an HF kit and structured follow-up phone calls for adults recently discharged with HFpEF to reduce medication errors and readmissions.

Quick facts

• Phase: NA
• Study type: Interventional
• Enrollment: 150 (estimated)
• Ages: 18 Years to 90 Years
• Sex: All
• Sponsor: Hackensack Meridian Health (other)
• Locations: 1 site (Brick, New Jersey)
• Trial ID: NCT06937827 on ClinicalTrials.gov

What this trial studies

The program expands an existing multidisciplinary Transitions of Care Clinic (pharmacist and nurse practitioner) to bridge care between hospital discharge and outpatient providers for patients with heart failure with preserved ejection fraction (HFpEF). Participants discharged home from Ocean University Medical Center receive an HF kit, education, tools, and scheduled follow-up phone calls to reinforce medications, symptoms, and outpatient follow-up. The intervention focuses on older adults and those with social or health literacy vulnerabilities who are at higher risk for readmission or adverse events. The clinic aims to connect discharged patients to their outpatient teams and reduce preventable post-discharge problems.

Who should consider this trial

Good fit: Adults aged 18–90 discharged home from Ocean University Medical Center after an inpatient admission for HFpEF exacerbation who can provide their own consent and participate in phone follow-up.

Not a fit: Patients discharged to facilities, those discharged with homecare or hospice services, those on hemodialysis, with dementia or without capacity, pregnant patients, or those who refuse phone follow-up are not expected to benefit from this program.

Why it matters

Potential benefit: If successful, the program could lower early post-discharge medication errors and hospital readmissions and improve patient self-management.

How similar studies have performed: Multidisciplinary transitional-care programs for heart failure have previously reduced readmissions in broader HF populations, though HFpEF-specific evidence is more limited.

Eligibility criteria

Inclusion Criteria:

* Adults ages 18 to 90 years old discharged from Ocean University Medical Center (OUMC)
* Inpatient admission for heart failure with preserved ejection fraction (HFpEF) exacerbation
* Patient discharged home with or without homecare

Exclusion Criteria:

* Refuse to participate in TOCC phone calls
* Discharged to a facility
* Discharged with homecare services
* Discharged on hospice services
* Hemodialysis
* Leave against medical advice (AMA)
* Pregnant
* Diagnosed with dementia
* Without medical capacity or unable to provide own consent

Where this trial is running

Brick, New Jersey

• Ocean University Medical Center — Brick, New Jersey, United States (RECRUITING)

Study contacts

• Principal investigator: Alexandria Berns, PharmD — Hackensack Meridian Health
• Study coordinator: Alexandria Berns, PharmD

Conditions: Heart Failure With Preserved Ejection Fraction, Discharge plans, heart failure with preserved ejection fraction, Readmissions, transition of care