"So my name is Ruth Masterson Creber, I'm a professor at Columbia University School of Nursing.

So patients of heart failure over 65 are the number one group to have readmissions of hospitalizations in the United States. This puts a tremendous cost both on patients and caregivers and families, psychologically and also financially, but it's also a huge financial burden on hospitals.

So hospitals have been really trying to figure out these transitions of care models to be able to help prevent these future rehospitalizations and to improve patients health status after a hospitalisation. And that's really what this study was about. It was about comparing two innovative and existing transitions of care models for patients with heart failure.

So we took two existing transitions of care models and did a comparative effectiveness study. This was a pragmatic randomised clinical control trial, was actually funded by PCORI which is a patient centres outcome research institute that funds these comparative effectiveness studies with patient centred outcomes.

The transitions of care coordinator included a nurse care coordinator that called patients 40 to 72 hours after discharge to to support them with their transition needs. And we compared that to mobile integrated health and this is a very novel kind of transitions of care programme. And patients got access to that nurse care coordinator but in addition the nurse care coordinator gave them access to a community paramedic who would actually go into the patient's home and support them with med reconciliation, a safety screen and they facilitated a telehealth visit with an emergency medicine doctor and then the nurse care coordinator provided that ongoing care management for those patients as long as they need it.

So we compared these two different programmes once again in a randomised one to one fashion.

So one of the distinctives of this study, and I think what really sets it apart from a lot of other heart failure trials, is the patient population and the representation of the patients that we were able to recruit. In our sample of over 2000 patients we had 2003 52% so the majority were women, 47% were black, 27% were Hispanic and patients also had a very high burdens of poor social determinants of health. 40% didn't have enough money to make ends need and 72% only at a high school education or less. So this is a really unique patient population.

What we found here in terms of our co primary outcomes is that there was no difference in actual health status or readmissions between the two arms but we had strong interaction effects firstly for health status by age, where patients who were younger compared to older heart failure patients did much better in the mih arm, they're 4.5 points higher health status in the MIH arm. And for re hospitalizations women, there was a strong interaction effect by sex where women in the mobile integrated health arm had a 30% reduction in their hospitalizations.

So even though overall, you know, technically this was a null trial, but you have to look at the interaction effects and look specifically at the patient populations who benefited most and what we know, especially in this patient population where it was a very vulnerable patient population that these younger heart failure patients and women were most likely to benefit.

Well, I think that this really highlights the vulnerable period and that transition of care period, and how our care models really need to include that. Oftentimes we think disparately about either acute care or home care, and I think this is really that bridge programmes like this are that bridge to be able to support both and to work synergistically.

And I think that for many of our most vulnerable patients, we need to remember that building the evidence base about these transitions programmes and what can work best for these patients is really important. And I think that programmes like Mobile Integrated Health can really be part of a solution in this vulnerable period for patients.
Firstly, I think this trial shows that we can recruit a diverse patient population and that we can have over 50% women in some of these trials. So I really want to encourage us and encourage the field to be able to do better in terms of representation of our trial participants.

And secondly, what we want to do next with mobile integrated health is really try and figure out how to optimise this for the patients that need it most. We don't think that this is probably a programme that's appropriate for every single patient with heart failure, but we really want to offer this high quality programme to the patients who are most likely to benefit.”