Transitional Care Interventions for Heart Failure Management
Summary
Transitional care interventions for heart failure encompass structured processes and services designed to ensure continuity of care as patients move from hospital settings to home or community environments. These interventions typically integrate discharge planning, medication reconciliation, patient and caregiver education, follow-up appointments and telehealth monitoring to reduce gaps in communication and enhance self-management. Core components include tailored educational materials on symptom recognition and lifestyle modifications, coordination among multidisciplinary teams and remote data collection to detect early signs of decompensation. By addressing physical, psychological and social determinants of health, transitional care interventions aim to lower hospital readmission rates, improve quality of life and foster adherence to evidence-based therapies. Despite proven benefits in cohort and economic studies, challenges remain in tailoring interventions to diverse patient populations, optimising resource use and sustaining engagement over time.
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Transitional Care Interventions for Heart Failure Management publication trend
The graph below shows the total number of articles in transitional care interventions for heart failure management across all publications each year (not limited to Nature Index journals).
Technical terms
Transitional care: A coordinated set of actions to ensure continuity of healthcare as patients move between locations or levels of care.
Virtual ward: A healthcare delivery model that provides hospital-equivalent monitoring and treatment in a patient’s home using multidisciplinary teams and remote technologies.
Guideline-directed medical therapy (GDMT): Use of medication regimens recommended by clinical guidelines to manage heart failure and improve patient outcomes.
Telemonitoring: Remote collection and transmission of physiological data (such as weight or blood pressure) to guide clinical decision-making.
Self-management: Patient engagement in daily activities and behaviours—such as symptom monitoring and medication adherence—necessary to manage chronic heart failure.
References
- Economic evaluation of the Liverpool heart failure virtual ward model. European Heart Journal - Quality of Care and Clinical Outcomes (2024).
- The Impact of Specialised Heart Failure Outpatient Care on the Long-Term Application of Guideline-Directed Medical Therapy and on Prognosis in Heart Failure with Reduced Ejection Fraction. Diagnostics (2024).
- Transitional Care Interventions for Patients with Heart Failure: An Integrative Review. International Journal of Environmental Research and Public Health (2020).
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