PCC- Impact at admission and discharge process, among patients with chronic heart failure

• Background: Chronic heart failure (CHF) mostly affects the elderly and is a lifelong and progressive disease and the single most common cause of hospitalization with frequent re-admissions. Although many patients with CHF are independent, some patients are fragile and need extra support and care during the hospital stay and after discharge to prevent disability. A person-centred care (PCC) approach to care and planning may help to promote more efficient care and discharge-planning. Aim: To evaluate if PCC-based proactive care-planning, beginning already at admission, leads to improved efficiency in the discharge procedure compared with usual care in patients hospitalized for worsening CHF. Methods: Using a controlled before-and-after design, eligible patients with CHF were randomly assigned to either a usual care group or a PCC intervention group. Development of the PCC care and discharge plan consisted of three steps: 1) a comprehensive narrative was obtained from the patients at admission to identify each patient’s resources for and barriers to recovery; 2) a PCC plan was drawn up based on this and other clinical information and discussed with the patient Downloaded from cnu.sagepub.com at Gothenburg University Library on December 15, 2013 EuroHeartCare 2013 S67 3) the PCC plan was checked and revised where appropriate. The patients’ social situation before admission, their discharge destination, the number of days until the discharge notification was sent to the patients’ community home help service/district nurse were recorded as well as the time interval between notification and start of coordination of care between hospital staff and community home help services and district nurses. Results: 123 in the usual care group and 125 were enrolled. Most of the patients came from independent living (93.2% in the PCC group and 93.5% in the usual care group). The proportion of patients who had community home help service before admission was slightly lower in the PCC group (32.4%) compared to the usual care group (35.8%). The proportion of patients who received care from a district nurse was slightly higher in the PCC group (18.9%) than in the usual care group (13.1%). During hospitalization, the notification to the patients community home help service and/or district nurse were significantly (P = 0.04) more frequently in the PCC-group (33.8%) compared to usual care group (12.1%). Care coordination started within six days in the PCC group whereas the usual care group was more dispersed 1-29 days. Conclusion: PCC improved significantlythe efficiency of the transfer process for patients in need of community home help service and/or district nurse after discharge.

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MEDICIN OCH HÄLSOVETENSKAP  -- Hälsovetenskap (hsv//swe)

MEDICAL AND HEALTH SCIENCES  -- Health Sciences (hsv//eng)

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