A pilot ranDomisEd trial of nurSe-led patIent follow-up using a diGital platform to reduce re-admissioNs after an acute presentation with Heart Failure. (DESIGN-HF)

DESIGN-HF is a randomised study to measure the usefulness of the Personify Care clinical pathway/ surveillance platform to both the patient and heart failure (HF) care team, and assess its potential impact on HF hospital readmission. Potential participants will be assessed for their ability to use a website on a digital system (eg. mobile phone, tablet, or computer) and regularity of access to such a device and internet/wifi. This will determine if participants are eligible to take part in the study. The assessments conducted by Heart failure nurses (HFN) have been translated into a digital platform, PersonifyHF. After gaining informed consent, participants randomised to the intervention arm will receive a text message prompting them to register on the PersonifyHF platform. During the follow-up period participants are prompted via text messages to log in and complete assessments usually performed over the phone by a HFN. During the online assessments participants will be prompted to answer additional questions depending on answers given. This includes the additional questions the HFN asks as part of ascertaining overall status of their heart failure patient, and rephrases certain formal assessment questions in the same manner the HFN does while speaking with the patient when conducting such assessments over the phone. If certain answers to particular questions are given the participant will be prompted to take action which include calling an ambulance in the case of a life threatening emergency or to contact the HFN within a given time frame (e.g. within 2 hours). Depending on answers given in the assessment the database will flag the HFN to contact the participant within a certain time frame. The HFN will also be flagged to contact the participant if the online assessment has not been completed within 4 working days of scheduled. When the database flags a participants response the HFN will receive a text message informing them of the timeframe required to respond. The frequency of assessments are the same as standard telephone follow-up. The standard care model for HF post-discharge follow-up is based on the Australian Heart Foundation Heart Failure Clinical Guidelines. A more detailed description of the follow-up timeframes are given below. Recruited participants will be randomised 1:1 to the intervention and the standard care control: Control: Standard evidence-based transition of care nursing model; specifically: • Standard home visit 1-week post-discharge • Follow-up phone calls by nurse at 2, 4, and 6 weeks post-discharge • Follow-up phone calls by nurse at 3 and 6 months post-discharge • Nurse-initiated additional clinical care as directed by patient response, eg. investigative testing, medication adjustment, clinical appointments. Intervention: Protocolised contact and clinical care guided by nurse surveillance of patient-entered data using the Personify Care platform synergistically with the standard evidence-based transition of care nursing model; specifically: • Standard home visit 1-week post-discharge • Nurse surveillance of patient-entered data at 2, 4, and 6 weeks post-discharge • Nurse surveillance of patient-entered data at 3 and 6 months post-discharge • Nurse-initiated additional clinical care as directed by patient response, eg. investigative testing, medication adjustment, clinical appointments. Both groups: • Except for the digital platform evaluation which will be provided to the intervention group at the 6 month visit, all assessments throughout the project are as per standard HF care but via different methods for initial communication. • All participants will receive a standard, evidence-based transition of care home visit at 1 week post-discharge, regardless of study randomisation.