Team-based care for people with heart failure with preserved ejection fraction
Tests team-based care in adults with heart failure with preserved ejection fraction.
Plain-language title generated from the registry record
Registry title: Effects of a Multidisciplinary Integrated Care Model on Care Outcomes in Patients With Heart Failure With Preserved Ejection Fraction
Key facts
- Where
- Tainan, TaiwanSee the site
Where in Taiwan
- Chi Mei Medical CenterTainan, TaiwanNo longer taking part
Questions to ask the study team
- How often do I need to come in, and for how long each time?
- Are travel costs paid?
- Can I keep my own doctor?
- What happens if I want to stop?
Trial details
- Who runs it
- Chimei Medical Center
- Trial code
- NCT07798856
- Record updated
- 1 September 2026
- Original description
Heart failure with preserved ejection fraction (HFpEF) accounts for approximately half of all heart failure cases and is associated with frequent hospitalizations, poor quality of life, and limited effective treatment options. Fragmented, single-discipline care often fails to address the multiple comorbidities and self-management needs of this population.Read full original descriptionShow less
A Prospective Quasi-Experimental Study With Historical Control to Evaluate the Effects of a Multidisciplinary Integrated Care Model on Care Outcomes in Patients With Heart Failure With Preserved Ejection Fraction
Heart failure with preserved ejection fraction (HFpEF) accounts for approximately half of all heart failure cases and is associated with frequent hospitalizations, poor quality of life, and limited effective treatment options. Fragmented, single-discipline care often fails to address the multiple comorbidities and self-management needs of this population.
This study evaluates a Multidisciplinary Integrated Care Model (MICM) for patients with HFpEF, delivered by a coordinated team including cardiologists, case managers, pharmacists, dietitians, and rehabilitation specialists. The intervention group will receive structured team-based care, including regular follow-up, medication optimization, dietary and lifestyle counseling, and exercise guidance, in addition to standard cardiology care.
Using a prospective quasi-experimental design with a historical control group, this study compares clinical and patient-reported outcomes between patients receiving the multidisciplinary integrated care model and a historical cohort receiving usual care. The primary aim is to determine whether this integrated care approach improves outcomes such as heart failure-related hospitalization, functional status, and quality of life in patients with HFpEF.
Inclusion: Age 18 years or older; Hospitalized with a physician diagnosis of heart failure with preserved ejection fraction (HFpEF); Left ventricular ejection fraction (LVEF) ≥50% on echocardiography performed during the index hospitalization; New York Heart Association (NYHA) functional class III to IV; Able to communicate in Mandarin or Taiwanese and understand the study intervention; For the prospective intervention group: willing to participate and provide written informed consent. For the historical control group: existing medical record data will be collected under a waiver of informed consent.
Exclusion: Severe cognitive impairment without a family member or caregiver available to assist with the digital platform; Patients who elected hospice or palliative care as part of an advance care plan during the index hospitalization; Anticipated inability to complete post-discharge follow-up or lack of regular follow-up at the study institution's outpatient clinic; Length of index hospital stay less than 24 hours.