Project Summary

This research project is in progress. PCORI will post the research findings on this page within 90 days after the results are final.

What is the research about?

Heart failure occurs when the heart can’t pump enough blood to the rest of the body. People with heart failure may go to the hospital for symptoms such as shortness of breath and fatigue. Within a month of leaving the hospital, 25 percent of patients with heart failure return to the hospital.

Follow-up care from a doctor can help patients improve their health and avoid a return to the hospital. But patients may face barriers to making and keeping follow-up appointments. For example, few appointments may be available. Patients may also have difficulty getting transportation to and from appointments.

In this study, the research team is comparing two ways to improve the follow-up care that patients with heart failure receive after returning home from the hospital.

Who can this research help?

Results may help hospital administrators when considering ways to provide follow-up care to patients with heart failure after hospital discharge.

What is the research team doing?

The research team is enrolling patients with heart failure from two health systems in New York City. The team is assigning patients by chance to receive one of two types of care after hospital discharge.  In the first type, patients receive a phone call from a care transitions coordinator two to three days after discharge. The coordinator checks on patients, answers their questions, and connects them to clinical and social services.

In the second type, called mobile integrated health, patients receive a follow-up phone call from a nurse. Patients also have access to community paramedics, who can provide emergency medical care in patients’ homes. If a patient has a health concern, the paramedic examines the patient and consults with an emergency doctor via video conference. The paramedic may treat the patient at home or take the patient to the hospital.

The research team is checking patients’ medical records and insurance claims one, two, three, and six months after the initial hospital visit. The team is looking to see if patients return to the hospital and if they receive prescriptions for heart failure medicines. One, two, and three months after hospital discharge, the team is surveying patients about their quality of life, symptoms, functioning, self-care, and if they went to follow-up doctor visits. Finally, the team is talking with patients, caregivers, and staff at the health systems to learn about how well the hospitals are providing the two types of care.

Patients with heart failure, caregivers, and community paramedics are helping to design and conduct this study.

Research methods at a glance

Design Element Description
Design Randomized controlled trial
Population 2,100 adults ages 18 and older with heart failure and Medicare or Medicaid insurance
  • Mobile integrated health
  • Care transitions coordinator

Primary: all-cause hospital readmissions, health-related quality of life

Secondary: preventable emergency department visits, unplanned hospital readmissions, days at home after a hospitalization, symptoms and functioning, patient self-care, attendance at follow-up appointments, whether patient was prescribed heart failure medicines, functional status

Timeframe 1-month follow-up for primary outcomes

Journal Citations

Project Information

Ruth Masterson Creber, PhD^
The Trustees of Columbia University in the City of New York
Using Mobile Integrated Health and Telehealth to Support Transitions of Care among Heart Failure Patients

Key Dates

March 2020
December 2024

^Rainu Kaushal, MD, MPH, was the initial principal investigator of this study.


Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
Populations Populations PCORI is interested in research that seeks to better understand how different clinical and health system options work for different people. These populations are frequently studied in our portfolio or identified as being of interest by our stakeholders. View Glossary
Intervention Strategy Intervention Strategies PCORI funds comparative clinical effectiveness research (CER) studies that compare two or more options or approaches to health care, or that compare different ways of delivering or receiving care. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: October 18, 2023