Project Summary

PCORI implementation projects promote the use of findings from PCORI-funded studies in real-world healthcare and other settings. These projects build toward broad use of evidence to inform healthcare decisions.

This PCORI-funded implementation project is making a self-care program for patients with acute heart failure—shown to decrease heart failure-related readmission—part of standard practice at emergency departments, or EDs.

Heart failure occurs when the heart fails to pump blood as well as it should. When heart failure occurs or gets worse suddenly, it’s called acute heart failure, or AHF. Each year, more than 900,000 people develop AHF. Many patients go to the ED for care.

What is the goal of this implementation project?

Supporting patients after an ED visit for AHF may help improve their health and avoid return trips to the ED and hospital. A PCORI-funded research study found that one month after leaving the ED for AHF, patients in a self-care program, called GUIDED-HF, had fewer deaths, fewer return visits to the ED or hospital, higher ratings of their heart failure health status, and greater knowledge about AHF than patients who received usual care.

Based on these results, the project team is working to make the self-care program part of standard ED care.

What will this project do?

The project team is putting GUIDED-HF in place at four diverse EDs in Michigan and Oregon. The two Michigan EDs serve an urban, racially diverse population, while the two Oregon EDs serve a more dispersed patient population.

In the program, a self-care coach creates a custom care plan for patients. The plan includes help to find the right medicine and make follow-up appointments. The plan may also include advice on diet, weight, AHF warning signs, and quitting smoking. After the patient leaves the ED, the coach provides follow-up home visits or virtual visits and coaching calls.

The project team is working with sites to adapt the program for their healthcare teams, with coordinators and paramedics serving as self-care coaches. In Michigan, the paramedics provide home visits to patients in the program.

To help put the program in place, the project team is:

  • Working with sites to adapt materials for each ED  
  • Modifying electronic health record, or EHR, systems to alert coaches when clinicians refer patients to the program
  • Training ED staff to serve as coaches and deliver the program
  • Identifying staff champions at each ED who will promote and support the program
  • Holding calls every one to two weeks with self-care coaches and team members including staff champions
  • Providing feedback reports to project leads at the sites, including data on the number of patients being referred to and receiving the program

What is the expected impact of this project?

This project will demonstrate what’s required to make the self-care program part of standard care for patients with AHF when they are discharged from the ED. More than 2,800 patients with AHF will receive the program.

The project evaluation will assess how well the program works outside of the controlled setting of a clinical trial to improve patient health and reduce return visits to the ED and hospital.

More about this implementation project:

Stakeholders Involved in This Project

  • American Heart Association
  • PCORI-funded Stakeholders Technology and Researchers Clinical Research Network (STAR CRN)
  • Kaiser Permanente of Northern California

Implementation Strategies

  • Use clinical decision support
  • Adapt program materials and protocols to work for sites’ existing resources and workflows
  • Adapt the program to work with sites’ EHRs, including use of triggers, alerts, and tracking templates
  • Integrate clinical decision support tools into sites’ EHRs to support patient identification and enrollment, as well as program delivery
  • Provide sites with tools to support implementation, including a toolkit and tracking templates
  • Provide educational materials to patients
  • Train ED staff to deliver the program and serve as self-care coaches
  • Identify and prepare clinical champions at each ED
  • Provide EDs with audit and feedback reports
  • Provide technical assistance, including monthly phone calls, mentoring, and ongoing consultation
  • Partner with national stakeholder organization to develop plans for further program scale-up
  • Create an implementation toolkit to support broader implementation

Evaluation Outcomes

To document implementation:

  • Number and proportion of eligible patients referred to the program
  • Number and proportion of referred patients who enroll in the program
  • Number of staff delivering the program
  • Consistency of program use
  • Patient and staff surveys of program appropriateness, acceptability, and feasibility

To assess healthcare and health outcomes:

  • Number of AHF events, including deaths, ED visits, and hospital admissions within 30 days of ED discharge

Project Information

Sean P. Collins, MD, MSc
Vanderbilt University Medical Center
Implementation of a Self-Care Plan for Patients with Acute Heart Failure Discharged from the Emergency Department

Key Dates

March 2021
August 2024

Initial PCORI-Funded Research Study

This implementation project focuses on putting findings into practice from this completed PCORI-funded research study: Examining Whether a Self-Care Program Reduces Healthcare Use and Improves Health among Patients with Acute Heart Failure -- The GUIDED HF Study


State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Project Details Type
Last updated: September 26, 2023