Home Care in Heart Failure: Towards an Integrated Care Model

This editorial refers to ‘The WHICH? trial: rationale and design of a pragmatic randomized, multicentre comparison of home- vs. clinic-based management of chronic heart failure patients’ by S. Stewart et al., published in this issue on pages 909–916. Although it is generally accepted that multidisciplinary management and follow-up of heart failure (HF) patients can be effective to improve patient adherence, reduce hospital readmissions and improve survival,1,2 there is an ongoing discussion on the optimal model of HF management. Most HF management programmes aim at optimization of both pharmacological and non-pharmacological management and include assessment and intervention of risks and comorbidity, optimized medical management, patient education and self care management, follow-up, access to healthcare and psychosocial support.1–3 However, the most optimal model for HF management is not known. Recent large scale studies show that not all models are equally successful to improve outcomes and these results indicate that a sophisticated approach to HF management is needed.4–6 In this issue of the European Journal of Heart Failure, Stewart et al.7 present the design and rationale of the WHICH?-trial, a study that will add knowledge to the discussion on optimal disease management for HF patients. In this trial 280 patients (73% male with a mean age of 71 years) have been randomized to home (n = 143) or clinic-based (n = 137) post-discharge management. The composite primary endpoint is all-cause recurrent hospitalization or death during 12–18 months follow-up. Patients randomized to the clinic-based intervention receive care from a HF clinic at their tertiary hospital coordinated by a HF nurse. Those allocated to home-based intervention receive a comprehensive home visit at 7–14 days post-hospitalization by a HF nurse and a report is sent to their local general practitioner (GP) and cardiologist outlining key findings and recommendations, including the need for a community pharmacist review. The results of this trial will help us to better understand how HF management programmes affect health outcomes and may help to refine our approach to implementing them to ensure we apply the most cost-effective components.7 Although some earlier studies describe the effectiveness of home-based HF management programmes organized in primary care,2 the majority of these programmes are primarily hospital based, with care delivered at outpatient clinics, sometimes with outreach to patients’ homes by HF nurses. Structural involvement of primary care (general practitioners and/or specialized community-based HF nurses) in HF management programmes is still limited. However, both from the perspective of health care providers and the perspective of patients there are several reasons to support strengthening the role of primary care in the care for HF patients. First, by delivering HF care at the homes of patients a more comprehensive assessment of the home environment and social support system can be performed. Visiting patients at home is important to gain a total picture of the ability of patients to manage their HF at home. Furthermore, home-based care may provide better opportunities to involve family and other caregivers in the HF care which is effective in terms of gaining better adherence and preventing deterioration and hospital admissions.8 Secondly, most HF patients need care and counselling for a long-time period, with regular refreshment, tailoring, and reinforcement of knowledge and skills.9 Ending follow-up may lead to less adherence and adverse long-term outcome, as was described in a study that followed patients after closing down a HF management programme.10With the ageing population and the growing amount of patients visiting HF clinics, it is important to seek ways in which initial specialized (secondary) care and long-term follow-up in primary care can be integrated in order to be able to provide this care efficiently. Thirdly, there is an increasing number of patients that suffer from multiple co-morbid conditions, such as HF in combination with diabetes or chronic obstructive pulmonary disease or depression. Pharmacological, non-pharmacological treatment and adequate follow-up of these conditions needs to be fine-tuned, coordinated and adapted to their specific needs, since they might not benefit from a general disease management approach.11 Primary care plays a role as gatekeeper and case manager and is important in the diagnosis, follow-up, and the coordination of care for these complex patients. Concluding from a health care perspective, it is vital to integrate hospital-based care and home care to provide efficient HF management for a growing number of complex patients. From the perspective of the patients, additional reasons to optimize the role of primary care need to be considered. A growing number of frail HF patients who live alone may not be able to visit the HF outpatient clinic on a regular basis. Hospital-based HF management might not be the optimal mode of delivery of care and these patients could benefit more from high-quality home-based HF care.12 At the same time it is not clear which patients would benefit from which type of care delivery and more importantly what preferences patients have. As shown by the WHICH? investigators, it is important to consider these preferences to guarantee the success of an intervention.7 Stewart et al.7 discuss the difficulty in recruitment into their study which they assign to ‘entrenched preferences from a consumer and health professional perspective for each approach’, reflecting that some patients prefer being visited in the home (particularly if they are frail and having difficulty attending a hospital clinic). On the other hand, some patients undoubtedly prefer the idea of leaving their house, associating with other patients and seeing a range of health care workers at their local hospital.7 The Primary Care Council of the European Society of Cardiology describes an important role for primary care in the management of HF; stating that professionals and policy makers need to rethink their tasks, level of knowledge and how they deal with HF.13 Ongoing trials such as the WHICH? trial,7 the recently reported NorthStar trial14 and the ongoing COACH2 trial all describe the role, quality and strength of primary care in HF. These studies will provide data on possibilities of care delivered by primary care professionals according to quality standards. Eventually it is not a matter of who provides the best care for the HF patient but rather how we can provide patients with integrated care where health care professionals collaborate with each other in providing best care that fits patients in different situations and in different conditions. In our search to find the best ‘place’ for our care, we should be aware of the quality of HF management. As Swedberg and Ekman wrote almost 10 years ago we should focus on content not just on form.15 In HF management we need to consider shared-care protocols that involve close liaisons between cardiologists and GPs and nurses. Following the recent standard on the delivery of HF care of the Heart Failure Association of the European Society of Cardiology, delivery of care should be aimed at providing a ‘seamless’ system of care across primary and hospital care so that the management of every patient is optimal, no matter where they begin or continue their health-care journey.16