Abstract
Introduction: Health digitization and advanced dyadic science offer new opportunities to enhance the transitional care model for heart failure (HF). The T-FamE program a transitional care model integrating digital health and optimized carer support to enhance the post-discharge outcomes of HF patients. Hypothesis: The T-FamE was more effective than usual care to enhance self-care, perceived control, family function, HRQoL and hospital readmission of HF patients. Methods: From Aug 2021 to March 2022, a RCT randomized 170 post-discharge HF patients (mean age = 69.0; SD=11.5; NYHA Grade II/III/IV = 53.9/40.6/.5.5%. LVEF<40% =58.5%) to the T-FamE or usual care. The 12-week nurse-delivered T-FamE comprises an interactive mobile Apps, which allows i) proactive health monitoring with tailored autonomous guideline-based feedback; ii) family-centerd goal-setting on self-care, iii) personalized drug education, iv) mobile access to nurse, v) video-based HF compass for rehabilitation and self-care. The cardiac nurse conducted three monthly visits for family-based empowerment on disease management. Outcome evaluation by Self-care Heart Failure index, Self-care Self-Efficacy Scale, Control Attitude Scale, Family Functioning Device and EuroQoL at baseline and post-test. Results: Two-way analysis of covariance showed significant greater improvement of T-FamE group on self-care maintenance (F=21.46, p<0.001, η 2 p =0.113), management (F=22.52, p=0.01, η 2 p =0.118), symptom perception (F=69.70, p<0.001, η 2 p =0.29) and confidence (F=13.36, p<0.001, η 2 p =0.073) than the control. They have greater improvement in EuroQoL (F=5.78, p=0.017, η 2 p =0.033) and sense of control (F=5.78, p=0.017, η 2 p =0.033), and significantly lower number ore readmission in one year (-0.278 (95%CI=-0.54, -0.008, p=0.043). Conclusions: The T-FamE is effective to improve the self-care, HRQL and readmission outcomes. Digitalized transitional care model with optimized family support play explain the therapeutic benefits. Autonomous response to health monitoring data may enhance self-care decision-making.
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