The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality

Abstract

BackgroundAfter hospitalization for cardiac disease, older patients are at high risk of readmission and death. Although geriatric conditions increase this risk, treatment of older cardiac patients is limited to the management of cardiac diseases. The aim of this study is to investigate if unplanned hospital readmission and mortality can be reduced by the Cardiac Care Bridge transitional care program (CCB program) that integrates case management, disease management and home-based cardiac rehabilitation.MethodsIn a randomized trial on patient level, 500 eligible patients ≥ 70 years and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Included patients will receive a Comprehensive Geriatric Assessment (CGA) at admission. Randomization with stratified blocks will be used with pre-stratification by study site and cognitive status based on the Mini-Mental State Examination (15–23 vs ≥ 24). Patients enrolled in the intervention group will receive a CGA-based integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) before discharge and four home visits post-discharge. The CCRNs collaborate with physical therapists, who will perform home-based cardiac rehabilitation and with a pharmacist who advices the CCRNs in medication management The control group will receive care as usual.The primary outcome is the incidence of first all-cause unplanned readmission or mortality within 6 months post-randomization. Secondary outcomes at three, six and 12 months after randomization are physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden.DiscussionThis study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care.Trial registrationNTR6316. Date of registration: April 6, 2017.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3301-9) contains supplementary material, which is available to authorized users.

The Cardiac Care Bridge randomized trial in high‐risk older cardiac patients: A mixed‐methods process evaluation

“…Although education on the additional value of in‐hospital geriatric team consultation was part of the CCB training programme, a sceptical view on the actual contribution was mentioned, and cardiac nurses mentioned that they thought they were able to act on observed geriatric problems. Apparently, the current procedure in the CCB intervention, with protocolized geriatric team consultation, did not provide enough impulse for close collaboration (Verweij et al., 2018). An alternative approach in which geriatric teams work proactively on hospital wards, may overcome with these barriers.…”

“…Although the beneficial effects of cardiac rehabilitation in older patients have been documented, the participation rate is still very low (14% in Medicare beneficiaries), which is caused by factors such as comorbidities and functional limitations (Zullo et al., 2018). Therefore, a home‐based cardiac rehabilitation programme was integrated in the CCB programme (Verweij et al., 2018). In total, 60% of the CCB intervention patients participated in the cardiac rehabilitation programme.…”

“…Figure 2 provides an overview of the intervention. Full study details are published elsewhere (Verweij et al., 2018). Appendix S2 provides a description of the standard care system in the Netherlands.…”

“…To reduce the previously mentioned risks and to overcome the shortcomings in the continuity of care, we developed the Cardiac Care Bridge (CCB) nurse‐coordinated, interdisciplinary, transitional care programme, and evaluated it in a multicentre randomized trial in 306 frail, older (≥70 years) hospitalized cardiac patients in the Netherlands (Verweij et al., 2018) (Jepma et al, submitted). The intervention included case management, disease management and home‐based cardiac rehabilitation, integrated in the process from hospital to home.…”

“…In brief: the why , who , what , where , how and how much should be integrated in the evaluation of complex interventions (Conn & Groves, 2011; Craig et al., 2013). The ‘why’ is addressed in the introduction section and the items who , what and where are described in the CCB intervention protocol and are summarized in Appendix S1 (Verweij et al., 2018). Exploration of how and how much of the intervention was performed, supports interpretation of the study results and informs future intervention (re)design and implementation.…”