# Group Medical Visits in Heart Failure for Post-Hospitalization Follow-Up > **NIH VA I01** · PROVIDENCE VA MEDICAL CENTER · 2020 · — ## Abstract  DESCRIPTION (provided by applicant): The primary goal of this research project is to improve the health status and decrease hospitalization and death for patients discharged with heart failure (HF) via education to patients, disease monitoring and medication titration through shared medical appointments (SMAs). Studies have found patient self-care behaviors in HF (e.g. medication/dietary noncompliance) and health system factors (e.g. care discoordination, limited access, lack of education to patients and caregivers) played an important role in patient's health status and hospitalization risk to the extent that 50% of the readmissions were judged to be possibly/probably preventable. To address patient and system factors based on the Chronic Care Model, redesign of care delivery, via SMA's, can be a good solution to provide patient self- management support while also performing disease monitoring and medication management in an environment of peer support. We propose a randomized controlled trial to enroll patients within 6 weeks of discharge from a HF hospitalization and randomized them to receive either SMA intervention every other week for 8 weeks versus usual care for HF. We will determine, at 180 days from randomization, whether HF patients who participate in HF-SMA, as compared to patients who receive usual care: 1) Experience better cardiac health status measured by Kansas City Cardiomyopathy Questionnaire (primary outcome), and overall health status (EQ5D, secondary outcome); 2) Have fewer hospitalization or death and 3) Experience improvement in intermediate outcomes: a) increase in HF Self-Care behavior, and b) decrease in plasma BNP levels. For patients who underwent HF-SMA, we will also determine perceived benefits, areas in need of improvement, potential obstacles of implementation, and fidelity of the intervention across sites, by conducting (a) face-to-face interviews with patients and (b) telephone interviews with stakeholders (physicians of the patients and administrators). The sites will be Providence VA and Phoenix VA hospitals to enroll a total of 375 patients. The study duration will be 180 days for all patients from the time of randomization. We will use stratified (enrollment in other programs for HF care, <2 hospitalizations last 6 months, left ventricular ejection fraction <40%), block randomization with block sizes of 4 in each site to ensure balance of the stratified variables. The team will consist of a nutritionist, nurse, health psychologist an a clinical pharmacist or nurse practitioner, without the presence of a physician (cardiologist will b available on call). The session will start with an assessment of patient needs followed by pre-assigned theme-based disease self-management education, followed by patient-initiated disease management discussion, and conclude with break-out sessions of individualized medication case management. Our study findings will be used in health care management and system re... ## Key facts - **NIH application ID:** 10178103 - **Project number:** 5I01HX001800-04 - **Recipient organization:** PROVIDENCE VA MEDICAL CENTER - **Principal Investigator:** WEN-CHIH WU - **Activity code:** I01 (R01, R21, SBIR, etc.) - **Funding institute:** VA - **Fiscal year:** 2020 - **Award amount:** — - **Award type:** 5 - **Project period:** 2015-07-01 → 2020-03-31 ## Primary source NIH RePORTER: https://reporter.nih.gov/project-details/10178103 ## Citation > US National Institutes of Health, RePORTER application 10178103, Group Medical Visits in Heart Failure for Post-Hospitalization Follow-Up (5I01HX001800-04). Retrieved via AI Analytics 2026-05-22 from https://api.ai-analytics.org/grant/nih/10178103. Licensed CC0. --- *[NIH grants dataset](/datasets/nih-grants) · CC0 1.0*