At a glance
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A Nurse-Led, Multidisciplinary mHealth Program to Manage Heart Failure During the Vulnerable Post-Discharge Period
In Brief
A clinical study evaluating Nurse-Led mHealth Multidisciplinary Management and Routine Outpatient Follow-Up for Heart Failure. Completed, enrolled 104 participants across 1 site.
Detailed Summary
Heart failure is a serious condition where the heart cannot pump blood as well as it should. After being discharged from the hospital, patients with heart failure are at high risk for readmission, especially in the first three months. This period is called the "vulnerable phase." Standard care often involves follow-up visits, but patients may struggle to manage their health at home. This study tested a new approach to care. The program is led by a nurse and uses a mobile health (mHealth) application on a smartphone. The app helps patients manage their health by providing daily medication reminders, tracking their weight and symptoms, and offering educational information. A team of doctors, pharmacists, and nurses work together to monitor patient data through the app. If any concerning signs appear, the team discusses the case and provides timely guidance to the patient. The study enrolled 100 patients with heart failure. Half of them received this nurse-led, app-based program in addition to their regular follow-up care. The other half received only the regular follow-up care. We measured how well patients managed their own care, how they felt (their symptoms), and key health indicators like heart function and a blood marker called NT-proBNP. We compared the two groups after three months.
Study Details
Timeline
Interventions
The intervention group received a nurse-led, multidisciplinary program via the Cardiovascular Home Care APP, in addition to conventional follow-up care. Team: 4 physicians, 4 nurses, and APP use. 1.Pre-discharge APP training: daily tasks, report upload, online consultation. APP automatically linked to patient information upon discharge.2.Nurse-created plans: medication schedules, self-monitoring (BP/heart rate/weight/symptoms), follow-up appointments, with reminders.3.Regular tailored education via APP (trigger avoidance, risk control, sodium/fluid restriction, symptom recognition, exercise).4.Daily nurse monitoring via backend. Alerts (non-adherence ≥7 days; BP fluctuation \>20%; medication intolerance; weight gain \>2kg/3 days; volume overload symptoms) triggered nurse contact and multidisciplinary discussion for treatment adjustments.5.Structured telephone follow-up at week 1; additional calls as needed.6.Dynamic plan updates during clinic visits.
Participants in the control group received conventional follow-up care. This consisted of standard outpatient clinic visits at 2 weeks, 1 month, 2 months, and 3 months after hospital discharge. The follow-up clinic was operated by a dedicated "physician-pharmacist-nurse" team. During these visits, the physician conducted clinical assessments and adjusted treatments as necessary. In the intervals between physician consultations, the pharmacist and nurse performed evaluations of disease knowledge and self-care behaviors, delivering individualized health education. Patients were provided with a health education handbook containing information about heart failure and logs for recording blood pressure, heart rate, body weight, and self-reported symptoms. They also received instruction on how to perform self-monitoring and apply the results to guide their self-care practices.