Timely Interventions to Enable and Reach Patients With Heart Failure, and Their Caregivers With Palliative Care

Summary

There is evidence for the effectiveness and feasibility of the individual components of TIER-HF-PC, however there is a need to test how these individual components interact to allow the researchers to deliver TIER-HF-PC as a model of care in its totality. In the short term, this study will assess if TIER-HF-PC is beneficial for patients and caregivers.

Eligibility

Inclusion Criteria:

* Patients:

  1. 21 years or older and
  2. able to communicate in English or Chinese and
  3. be of stage C or D heart failure, as defined by American College of Cardiology/American Heart Association (ACC/AHA) classification system and
  4. have functional limitation of New York Heart Association (NYHA) functional status of at least 2 or more and
  5. be deemed by their cardiologist's clinical judgement to have an expected prognosis of at least 6 months survival, and
  6. have had a heart failure related hospitalization event (e.g. symptomatic decompensated heart failure) within 6 months prior to recruitment and
  7. have a phone that allows telecommunication.
* Caregivers must meet all the following inclusion criteria to be eligible for the study :

  * direct, unpaid, family caregiver of the patient;
  * self-reported by the patient to be the main person to be either:
  * responsible for up to 4 hours a day of caregiving tasks
  * and/or decision maker/spokesperson with the medical team
  * Caregiver may or may not live in the same residence as the patient.
  * Caregivers must be 21 years and above.
  * Able to communicate in English or Chinese.

Exclusion Criteria:

* Patients:

  1. have cognitive impairment (e.g., dementia)
  2. have severe, untreated, active mental illness (e.g., major depressive disorder)
  3. have ventricular assist device implant.
  4. have non-reversible hearing or visual loss or
  5. are active drug abuser or
  6. already known to a palliative care service.
* Caregivers who meet any of the exclusion criteria at baseline will be ineligible for the study:

  * have cognitive impairment (e.g., dementia) or
  * have severe, untreated, active mental illness (e.g., major depressive disorder)
  * have non-reversible hearing or visual loss.
  * are active drug abuser or
  * are a domestic helper for the patient

Conditions2

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