Design and development of a model for home care in advanced heart failure

Background Managing advanced heart failure (HF) is particularly challenging in the elderly, with high mortality rates and frequent unplanned hospitalizations in the final months of life. A tailored home care model may improve quality of life and reduce hospital admissions, especially when acute hospital care has limited impact on disease progression. Emerging technologies such as telemedicine, combined with home care for acute illness, are opening new avenues for delivery of care. Purpose To develop a comprehensive model for home-based care in advanced HF using co-creation and user-experience (UX) design, engaging key stakeholders involved in patient-centered care. We hypothesized that telemedicine, home care and availability of advisory clinical support around-the-clock were essential for providing a safe, specialized and supportive care model. Methods In a collaboration between two university hospitals we assembled a team of professional stakeholders closely involved in patient care, conducting four workshops led by a project leader and a UX designer to identify both professional and patient needs for designing a feasible home care model for patients with advanced HF. The stakeholder group comprised 6 specialist nurses (representing cardiology, Hospital@Home, municipal care, primary care, telemedicine) and 6 specialist physicians (representing cardiology, geriatrics, internal medicine, and palliative medicine). Results Patient and caretaker journeys were mapped, and key areas of care examined during the workshops, focusing on patient and caretaker needs (Table). This process resulted in a structured model for home-based care in advanced HF, emphasizing availability of four specific areas for feasibility: Clinical consultant 24/7, structured remote monitoring, planned clinical follow-ups over time, and a well-defined care plan in the medical records (Figure). A patient enrolled in the program could transition between additional care providers as needed, while remaining within the program, as illustrated in the Figure. Conclusion We have developed a home care model for advanced HF through co-creation and UX design, involving professionals closely engaged in patient care. Next steps include interviews with patients and next-of-kin for further refinement, followed by a clinical trial comparing specialized home care with standard care.Areas of care addressed in workshops Model for home care in advanced HF