A Remote Management-Centric Post-Discharge Pathway for Patients Admitted to GIM with Heart Failure

William K Silverstein; Sarah Lawrason; Iris Carabuena; Rodrigo B Cavalcanti; Stella Kozuszko; Thomas E MacMillan; Shail Rawal; Lara Wyss; Anne Simard; Heather J Ross; Tarek Abdelhalim

doi:10.1016/j.amjmed.2024.12.017

A Remote Management-Centric Post-Discharge Pathway for Patients Admitted to GIM with Heart Failure

Am J Med. 2024 Dec 26:S0002-9343(24)00846-5. doi: 10.1016/j.amjmed.2024.12.017. Online ahead of print.

Authors

Affiliations

¹ Department of Medicine, University of Toronto, Toronto, ON, Canada; Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, ON Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON Canada; HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, ON, Canada. Electronic address: [email protected].
² Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON, Canada; Public Health Agency of Canada, Ottawa, ON, Canada.
³ Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
⁴ Department of Medicine, University of Toronto, Toronto, ON, Canada; HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, ON, Canada; Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, ON, Canada.
⁵ Integrated Comprehensive Care Program, University Health Network, Toronto, ON, Canada.
⁶ Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON, Canada; Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
⁷ Department of Medicine, University of Toronto, Toronto, ON, Canada; Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON, Canada; Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.

PMID: 39732153
DOI: 10.1016/j.amjmed.2024.12.017

Abstract

Background: Few GIM-specific heart failure transition of care (TOC) programs exist. We thus piloted a TOC program for heart failure patients discharged from GIM that incorporates a remote patient management program, Medly.

Methods: This single-centre, prospective proof-of-concept study described sociodemographic and medical characteristics of included patients, and computed summary statistics to describe clinical and workload outcomes.

Results: Ten patients (median age: 85) enrolled. There was no heart failure-related deaths, re-hospitalizations, or ED visits within 90 days of hospital discharge. One urgent GIM clinic visit was needed.

Conclusion: This post-GIM TOC pathway appears to effectively support heart failure patients. Further studies should assess this innovation's scalability.

Keywords: Heart Failure; Hospital Medicine; Remote Patient Management; Transitions of Care.