Feasibility Study of a Nurse-Led Home Return Program for Heart Failure Patients
Tests a coordinated home return program in adults with heart failure after hospital stays.
Plain-language title generated from the registry record
Registry title: Feasibility Study on the Implementation of a Program to Facilitate the Return Home of Patients With Heart Failure Following Hospitalization, Led by a Coordinated Multidisciplinary Team Based on the "Team-based Care" Model
Key facts
- Where
- Besançon, FranceSee the site
Where in France
- MSP " Sant'Innovation " de PalenteBesançon, FranceNo 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
- Sant'Innovation
- Trial code
- NCT07849361
- Record updated
- 5 October 2026
- Original description
Heart failure is a common heart condition that often leads to hospital stays and repeat readmissions. When patients leave the hospital, coordinating patient care between the hospital and the local healthcare team (family doctor, nurses, cardiologist) can be difficult, and gaps in this coordination can lead to complications or unnecessary re-hospitalizations.Read full original descriptionShow less
Feasibility Study on the Implementation of a Program to Facilitate the Return Home of Patients With Heart Failure Following Hospitalization, Led by a Coordinated Multidisciplinary Team Based on the "Team-based Care" Model
Heart failure is a common heart condition that often leads to hospital stays and repeat readmissions. When patients leave the hospital, coordinating patient care between the hospital and the local healthcare team (family doctor, nurses, cardiologist) can be difficult, and gaps in this coordination can lead to complications or unnecessary re-hospitalizations.
This study, called TEAM-IC, tests a new way of organizing the return home after a hospital stay for heart failure. In this new approach, a dedicated "care coordination nurse" based in a local primary care health center works closely with the patient's usual caregivers and with the hospital team to support the patient during the first three months after discharge. This is compared to the existing standard program (PRADO-IC) currently used in France.
Hypothesis: The investigators believe that organizing the return home around a coordinating nurse embedded in a local health center, with support tailored to each patient's level of frailty, will lead to better follow-up and better care for heart failure patients than the current standard program.
Before testing whether this approach actually improves health outcomes in a larger trial, this study first aims to find out whether such a program is realistic and workable in practice, for example, whether patients and healthcare professionals are willing to take part, whether the organization runs smoothly, and whether the study procedures can be followed as planned.
Inclusion: Male or female, age > 18 years with no upper age limit; Hospitalized for heart failure; Discharge home anticipated within 7 days of enrollment; Signed and dated informed consent; Resident within the GHT Centre Franche-Comté and within a maximum of one hour by road from one of the two enrolling centers.
Exclusion: Needfor a heart transplant or ventricular assist device; Any severe valvular heart disease that could benefit from surgical intervention during the course of the study; A person subject to a legal protection measure, involuntary psychiatric care, unable to give consent, to follow instructions, or to comply with follow-up procedures; Any other medical condition that would put the patient at risk or could influence the study results; Patient currently enrolled in an ongoing interventional clinical research study on heart failure management (risk of interference); Patients with a life expectancy of less than 3 months; Not affiliated with or not a beneficiary of a French social security scheme; Subject in the exclusion period of another study or listed in the "national register of volunteers" ("fichier national des volontaires"); Patient already benefiting from a home discharge program other than the PRADO program.