RecruitingNCT05417490

Research Into Factors Determining Participation in 2 Interventions Modifying the Care Pathways of Patients With Heart Failure: PRADO and Telemedicine

Research Into Factors Determining Participation in Two Interventions Modifying the Care Pathways of Patients With Heart Failure in Eastern Occitanie: PRADO-IC and Telemedicine

Sponsor

University Hospital, Montpellier

Enrollment

700 participants

Start Date

Apr 1, 2025

Study Type

OBSERVATIONAL

Conditions

Heart Failure

Summary

Patients with heart failure (HF), after hospitalization, present a marked fragility. Interventions improving the coordination of care actors at the time of discharge from hospitalization have been tested and have shown, in preliminary studies, a reduction in rehospitalizations for heart failure and all-cause mortality. Among these promising devices, two have recently been deployed nationwide. * The return home program for IC patients (PRADO IC), set up by the Health Insurance, aims to facilitate the return and stay at home after hospitalization. It offers assistance with the initiation of outpatient medical follow-up, nursing follow-up for 2 to 6 months depending on the severity of the patient, and a follow-up log facilitating the exchange of information. * At the same time, as part of the ETAPES (Telemedicine experiments for the improvement of healthcare pathways) program of the Health Insurance, the deployment of telemedicine for remote monitoring of heart failure pursues a comparable objective of reducing rehospitalizations. These two systems are widely deployed on a national scale, and are intended to be universal. Our hypothesis is that adherence to care transition and telemedicine programs, and therefore their effectiveness, may depend on their association, as well as socio-demographic, cultural, and geographical factors.

Eligibility

Min Age: 18 Years

Inclusion Criteria3

Adult patient
Patient hospitalized at the time of inclusion for cardiac decompensation, or cause of admission for which heart failure plays a decisive or aggravating role (co-infection, etc.) recognized by the clinician.
Patient agreeing to take part in this research (absence of non-objection)

Exclusion Criteria3

Refusal to participate
Pregnant or breastfeeding women, patients unable to give protected adult consent, vulnerable people (art.L.1121-6, L.1121-7, L.1211-8, L.1211-9)
Subject deprived of liberty by judicial or administrative decision

Interventions

OTHERPRADO-IC

The CAM (Health Insurance Advisor) are part of the staff of the Primary Health Insurance Funds (CPAM). They are physically present in the establishments participating in the PRADO. They are facilitators between city health professionals and the patient for their return home. They assist the patient in making appointments with their general practitioner, their cardiologist, and the IDE (general care nurses) trained at PRADO-IC who will make the home visits. After returning home, the CAM verifies, by two telephone calls at 1 week and 2 months, that the patient has initiated his outpatient follow-up. IDE, trained in the therapeutic education of the IC patient according to the PRADO-IC device, carry out: * for NYHA (New York Heart Association) 1-2 patients: 8 home visits in two months. * for NYHA 3-4 patients: 8 home visits in 2 months, upon confirmation and prescription from the physician, 8 visits in the following 4 months. The doctor carries out a long consultation at 2 months.

DEVICERemote monitoring

Chronic Care Connect is intended for remote medical monitoring of patients suffering from chronic heart failure. It consists of a web application (named NOMHADChronic™) and non-medical remote human assistance performed by qualified personnel. Non-medical human assistance allows the following steps to be carried out: * characterization of alerts * structured follow-up of remote patients. This non-medical human assistance is provided by: * nurses trained in therapeutic education and cardiology, Customer Relations Advisors, and logisticians. Weight and symptoms (listed in an 8-question questionnaire) are collected respectively using a connected scale and the mobile application. It allows, via a web browser: * to the personnel constituting the non-medical human assistance, to have access to the health data of the patients * remote monitoring doctors, to have access to the health data of each of their own patients, and to carry out medical remote monitoring procedures.