Table 1 Examples of randomized controlled trials of heart failure transitional-care interventions

PACT-HF (Patient-Centered Care Transitions in HF) [55]

Ontario hospitals (n = 10, including 2494 patients whose reason for hospitalization was HF)

A transitional-care model that combined evidence-informed services with guideline recommendations and a patient-centered approach

No differences versus usual care in time to all-cause readmission or emergency department visit at 30 days after hospitalization

Pragmatic trial; randomization was at the hospital level; the intervention improved the exploratory outcomes of quality of care and discharge preparedness

CONNECT-HF (Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure) [56]

American hospitals (n = 161, including 5647 adults with HF with reduced ejection fraction)

A quality improvement intervention (versus usual care) designed to improve transition processes and guideline-directed medical therapy in people living with HF

The intervention did not result in better measures of quality of care or clinical outcomes

Randomization was at the hospital level

EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction) [57]

Adults with HF with reduced ejection fraction (n = 290) from the University of Colorado Health system

A patient activation tool (versus usual care) comprising a short video and single-page medication checklist; the tool encourages people living with HF to work collaboratively with their clinicians

The intervention was effective in improving guideline-directed medical therapies

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REACH-HF (Rehabilitation Enablement in Chronic Heart Failure) [58]

Adults with HF with reduced ejection fraction (n = 216)

A self-care, home-based, facilitated cardiac rehabilitation manual (versus usual care) offered over 12 weeks by trained health care professionals, plus usual care

There was a clinically meaningful difference in the Minnesota Living with Heart Failure Questionnaire score at 1 year (−5.7 points, 95% confidence interval −10.6 to −0.7 points) favoring the REACH-HF intervention (P = 0.025)

There was no significant difference in hospital admissions at 1 yr