heart failure ( hf ) is the most common cause of hospitalization for people over 65 .
the presence of multi - morbidity and frailty in older people with hf is associated with a decreased quality of life ( qol ) , a 92% increased risk for ed visits , and a 65% increased risk for hospitalizations .
hf prognosis follows a progressive , albeit non - linear course , whereby patients can die suddenly or progress to end - stage hf over time .
there is an escalation in the care needs of these patients as the disease progresses . at a system level , these patients rely on the coordination of several health - care providers in addition to informal services .
it has been shown that quality gaps and decreased patient safety often result from fragmented care caused by the lack of coordination and integration amongst these services . moreover ,
the literature highlights challenges with both patients and their caregivers understanding the importance of self - efficacy in chronic disease management such as hf .
in fact , the majority of hospital admissions are due to the lack of self - care support , medication management , and dietary adherence .
patient - level barriers to self - care include regimen complexity , undesirable medication effects , and inadequate knowledge , tools and support . even in advanced stages ,
hf patients and their caregivers are heavily and unnecessarily burdened by fragmented health - care services .
most importantly , there is evidence that these poor experiences could be dramatically improved by simple organizational and process changes , rather than complex clinical mechanisms .
understanding the perspectives of the patient , the caregiver , and the professional is crucial for the development of these organizational and process changes , leading to an optimal patient experience .
the objectives of this study were to determine both the patients and their caregivers perspectives and experiences with hf care ; and to explore the barriers to high - quality care at the geriatric medical unit ( gmu ) of the ottawa hospital .
this investigation would identify both the organizational and process changes needed to enable optimal hf management , resulting in improved patient satisfaction .
the focus included adherence to the gap ( guidelines applied in practice ) tool for patient hf education , better communication in self - care training , addressing advance directives , case coordination at the time of discharge ( dc ) , and transitional care planning .
gmu is a 20-bed unit that primarily receives patients on transfer from other acute care services at the ottawa hospital following a triage by the geriatric consult team .
these patients have a variety of medical , functional , cognitive , and psychosocial issues , resulting in challenging dc planning .
the gmu team consists of geriatric nursing , physiotherapy , occupational therapy , pharmacist , dietician , and social worker services .
the mandate of gmu is the assessment and optimization of conditions suitable for further rehab , transition to community living , or relocation to a facility .
this study was supported by a grant from the department of medicine quality improvement committee , university of ottawa , and received full research ethics board approval .
of the 36 eligible hf patients admitted during that period , 19 consented to participate in the study in addition to 18 caregivers .
quantitative data were gathered through chart reviews and electronic medical records ( emr ) including : age , ethnicity , educational level , marital status , gender , mental and physical function , multi - morbidities , and advance directives including decisions on end - of - life care .
medications upon admission and dc , as well as medications found on the beer s list were documented .
additional data were gathered by using assessment tools : function ( barthel & lawton scales ) , cognition ( moca & cam ) , mobility ( gait speed ) , balance ( berg s scale ) , multi - morbidity ( charlson index ) , and depression ( gds ) .
data analysis was done using fischer exact test for categorical variables and mann - whitney testing for continuous variables . in the qualitative part of the project ,
interviews took place in person during the hospital stay and over the phone two weeks post - dc . in these exploratory interviews , patient experiences and preferences with hf
content analysis was performed to identify recurrent themes , first performed by one researcher ( gl ) then verified for accuracy by a second researcher ( lk ) .
quantitative data analysis of the 19 consenting patients showed an average age of 85 ( 63% were female ) .
most participants lived alone ( 65% ) and 74% were living in their own home .
diastolic dysfunction was present in 73% of these in - patients and was significantly more common in females .
the other common multi - morbidities included : delirium in 74% , anemia in 74% , ckd in 68% , and atrial fibrillation in 47% .
the hf education ( gap tool ) had been ordered by the md in 74% of the hf patients .
discharge ( dc ) summary from md to the primary care physician ( pcp ) mentioned the patient s chosen code status in only 58% of the cases .
hf medications were prescribed such as beta blockers ( in 74% ) , and acei ( in 47% ) at the time of dc .
qualitative data analysis focused on evaluating three domains : service utilization , self - care teaching / communication , and end - of - life ( eol ) care ( see table 3 ) .
participants reported that fatigue , dyspnea , and edema were barriers to function and self - care , but only a minority of patients had community support in place to assist them .
most were living alone or relying on family members for help to remain as independent as possible .
notable challenges were reported by the patients in accessing their family physician , both in follow - up after dc and on an urgent basis leading to emergency room visits or readmissions .
three were unhappy with communication as  people were in and out of their room but not providing enough medical information 
,  information was only provided to family and the patient did not appreciate it  , and 
most participants did not recall getting any instruction on hf management ( i.e. , medications , diet , exercises ) .
the majority of patients recalled getting weighed and doing exercises everyday but were not sure why these were done :  staff does things but do not explain what they do  .
code status was do not resuscitate ( dnr ) for most participants , but for the ones who wanted to be resuscitated ,  they wanted this as long as there was a good chance of recovery  .
family presence at eol was described as important , but the concept of palliative care was new to most participants .
participants who received the hf information booklet were grateful and wanted to receive more education in the presence of their families .
other comments were related to patients feeling they did not receive enough nursing supervision , response to call bells , and help with toileting .
follow - up phone interviews within two weeks post - dc did not happen for five of the patients , as they were too sick to participate in the interviews .
the majority of patients ( 89% ) reported that they had a good relationship with their pcp but had not seen their doctors yet .
half of the patients reported that they did not know if they were on a special hf diet and were eating whatever was provided at their residence .
of the 18 caregivers interviewed , 14 ( 73% ) were directly involved with providing daily patient care ( 3 experienced heavy burden ) .
there was a concern about diet recommendations not being carried over to the retirement home upon dc .
caregivers did not appreciate being given too many written pamphlets as  it goes all in a pile and never gets read  .
seven caregivers ( 37% ) had concerns about the current dc plan since the majority of these patients ( 68% ) had prior poor experiences with hospital readmissions and ed visits .
premature dc and a lack of care coordination created resistance and uncertainty with the current dc plan .
most notably , these patients have a higher percentage of very old individuals with multi - morbidities and polypharmacy . functional limitations and cognitive changes are prevalent .
although we need a great deal more clinical research with older people , it should come as no surprise that conducting this type of research can be problematic .
a review of the literature in this area provides some indication of the challenges of doing qualitative studies .  
our findings will apply to the many healthcare systems with a similar structure for cardiogeriatric care .
the gmu is comprised of many clinical disciplines that utilize a complex network / web of care processes tuned over the years to provide the current results .
if we are serious about improving clinical results , we must accept that the system must change .
a quality assurance program should be developed to re - engineer processes to ensure they are both focused on the patient s goals and preferences while being compliant with best clinical practice .
based on patient feedback , our discussion focuses on two areas : gmu items and patient / caregiver items .
we identified specific clinical recommendations that should be implemented immediately and should be part of any process re - engineering and quality assurance program .
for example , the gap tool was ordered in only 74% of the cases by mds when the patient was admitted to gmu .
this can be rectified by a better orientation of physicians and trainees to achieve a rate of 100% compliance .
discussion of code status , prognosis , and documentation in the chart in addressing advance care planning ( acp ) can also be enhanced from 58% of the cases to 100% during the eol discussions .
in addition to clinical process re - engineering , survey results recommend organizational changes between the geriatric consult and the gmu teams leading to better selection of patients for gmu transfer .
direct transfer to palliative care would better serve some candidate patients . in this study five
patients continued to do poorly during their gmu stay and post - dc , too ill to even participate in a survey phone interview .
unfortunately for these patients , the appropriate focus on symptom management and eol issues was not done .
inappropriate patient selection for the gmu results in suboptimal use of gmu skills and resources , blocking access for other better suited patients .
consistent with the literature , this study noted many addressable factors that contribute to undesirable dc preparation . these include inadequate attention to qol issues ; poor symptom management ; caregiver burden and their competency ; complex medication regimen with a high potential of error and duplication ; discharged too quickly .
improved provider - to - provider communication can be achieved by better documentation of medical goals of care , clarity on hf specific recommendations such as achieving targets ( e.g. dc weight , bp & hr ) , management of weight , sodium restrictions , diuretic use , and evidence - based medications .
furthermore , changes in hf medications from pre- to post- hospital stay should be in the summary letter to pcp .
finally , planning for advanced directives , life expectancy discussion , and total status reconciliation of cognitive , function , social support and expectation post - acute care are also needed in the dc summary . in our survey
, we found that only 37% had hf - specific recommendations included in dc summaries to pcp .
the gmu needs to provide job aids / tools to rotating mds to establish consistency in required information dictated in dc letters and minimize the variability in the quality of dc summaries .
the canadian and the american consensus guidelines strongly recommend that clinicians should initiate and facilitate regular discussions with patients and family regarding advance care planning ( acp ) .
this discussion can be planned as part of a dc plan checklist , with early follow - up and discussion based on the path model .
regardless of the quality of the dc plan , gmu does not track the success of the plan .
gmu organization should be extended to encompass outpatient cardiogeriatric clinics to follow hf patients and to receive feedback from the patient , caregiver , cardiologist , and pcp post - dc .
the dc plan implementation would be owned by gmu and prevent difficulties accessing pcp care post - dc . in our study , none of the patients was seen within the first two weeks post - dc .
we need to enhance patient / caregiver recollection of the hf diagnosis , management , and self - care .
we should provide better explanations regarding what patients must get right in their self - care , such as weight monitoring , adherence to hf diet , and exercise .
this can be achieved by providing a medical information package to both patient and caregiver that includes simple information about the diagnosis and easy - to - follow instructions .
unfortunately , cognitive impairment ( ci ) is often under - recognized in this population .
ci diminishes the ability to follow lifestyle changes such as salt / fluid restriction , and following medication regimen and activities .
therefore , a systematic review of the medical information package with the caregiver can enhance adherence to the team s recommendations .
the use of phone calls from a hospital designated individual can be used to reinforce and offer clinical support for the dc plan recommendations and promote adherence to the plan .
again , a quality assurance program would help ensure optimal results for dc plan compliance .
however , this is dependent on the patient undertaking a number of complex self - care behaviours .
consequently , there is a need to improve the understanding of patient perspectives and challenges related to self - care in order to enhance supportive interventions .
the way health - care professionals interact and communicate with patients strongly influences their understanding of their condition and subsequent behaviors .
effective self - care was more evident when patients perceived that their health - care professional was responsive , interested in their individual needs , and shared information .
these challenges suggest a need for new research and practice strategies that accommodate the increasing complexity of this frail population with hf . improved hf management needs to be tailored to make optimal use of enhanced hf self - care utilizing community resources , ambulatory care , and in - home support services .
a key component of this change is establishing novel cardiogeriatric clinics to facilitate geriatrician , cardiologist , and pcp teamwork , resulting in better ambulatory care management of multi - morbidity in hf and constructive feedback to inpatient gmu services .
however , our sample size was not different from the current literature for a qualitative study and is acceptable for a quality improvement project .
other limitations include the interview time period ( the interviews were conducted based on the patient s ability to answer questions ) .
we learned that it is crucial to plan strategies that accommodate the special circumstances of frail older patients with hf .
we had to allow more time for patients to adjust to their new environment and to be patient with them .
we used visual cues and repetition to assist patients with cognitive impairment to conduct the interviews .
we identified specific clinical recommendations that should be implemented immediately and should be part of any process re - engineering and quality assurance program .
for example , the gap tool was ordered in only 74% of the cases by mds when the patient was admitted to gmu .
this can be rectified by a better orientation of physicians and trainees to achieve a rate of 100% compliance .
discussion of code status , prognosis , and documentation in the chart in addressing advance care planning ( acp ) can also be enhanced from 58% of the cases to 100% during the eol discussions .
in addition to clinical process re - engineering , survey results recommend organizational changes between the geriatric consult and the gmu teams leading to better selection of patients for gmu transfer .
direct transfer to palliative care would better serve some candidate patients . in this study five
patients continued to do poorly during their gmu stay and post - dc , too ill to even participate in a survey phone interview .
unfortunately for these patients , the appropriate focus on symptom management and eol issues was not done .
inappropriate patient selection for the gmu results in suboptimal use of gmu skills and resources , blocking access for other better suited patients .
consistent with the literature , this study noted many addressable factors that contribute to undesirable dc preparation .
these include inadequate attention to qol issues ; poor symptom management ; caregiver burden and their competency ; complex medication regimen with a high potential of error and duplication ; discharged too quickly .
improved provider - to - provider communication can be achieved by better documentation of medical goals of care , clarity on hf specific recommendations such as achieving targets ( e.g. dc weight , bp & hr ) , management of weight , sodium restrictions , diuretic use , and evidence - based medications .
furthermore , changes in hf medications from pre- to post- hospital stay should be in the summary letter to pcp .
finally , planning for advanced directives , life expectancy discussion , and total status reconciliation of cognitive , function , social support and expectation post - acute care are also needed in the dc summary . in our survey
, we found that only 37% had hf - specific recommendations included in dc summaries to pcp .
the gmu needs to provide job aids / tools to rotating mds to establish consistency in required information dictated in dc letters and minimize the variability in the quality of dc summaries .
the canadian and the american consensus guidelines strongly recommend that clinicians should initiate and facilitate regular discussions with patients and family regarding advance care planning ( acp ) .
this discussion can be planned as part of a dc plan checklist , with early follow - up and discussion based on the path model .
regardless of the quality of the dc plan , gmu does not track the success of the plan .
gmu organization should be extended to encompass outpatient cardiogeriatric clinics to follow hf patients and to receive feedback from the patient , caregiver , cardiologist , and pcp post - dc .
the dc plan implementation would be owned by gmu and prevent difficulties accessing pcp care post - dc . in our study , none of the patients was seen within the first two weeks post - dc .
we need to enhance patient / caregiver recollection of the hf diagnosis , management , and self - care .
we should provide better explanations regarding what patients must get right in their self - care , such as weight monitoring , adherence to hf diet , and exercise .
this can be achieved by providing a medical information package to both patient and caregiver that includes simple information about the diagnosis and easy - to - follow instructions .
unfortunately , cognitive impairment ( ci ) is often under - recognized in this population .
ci diminishes the ability to follow lifestyle changes such as salt / fluid restriction , and following medication regimen and activities .
therefore , a systematic review of the medical information package with the caregiver can enhance adherence to the team s recommendations .
the use of phone calls from a hospital designated individual can be used to reinforce and offer clinical support for the dc plan recommendations and promote adherence to the plan .
again , a quality assurance program would help ensure optimal results for dc plan compliance .
however , this is dependent on the patient undertaking a number of complex self - care behaviours .
consequently , there is a need to improve the understanding of patient perspectives and challenges related to self - care in order to enhance supportive interventions .
the way health - care professionals interact and communicate with patients strongly influences their understanding of their condition and subsequent behaviors .
effective self - care was more evident when patients perceived that their health - care professional was responsive , interested in their individual needs , and shared information .
these challenges suggest a need for new research and practice strategies that accommodate the increasing complexity of this frail population with hf . improved hf management needs to be tailored to make optimal use of enhanced hf self - care utilizing community resources , ambulatory care , and in - home support services .
a key component of this change is establishing novel cardiogeriatric clinics to facilitate geriatrician , cardiologist , and pcp teamwork , resulting in better ambulatory care management of multi - morbidity in hf and constructive feedback to inpatient gmu services .
however , our sample size was not different from the current literature for a qualitative study and is acceptable for a quality improvement project .
other limitations include the interview time period ( the interviews were conducted based on the patient s ability to answer questions ) .
we learned that it is crucial to plan strategies that accommodate the special circumstances of frail older patients with hf .
we had to allow more time for patients to adjust to their new environment and to be patient with them .
we used visual cues and repetition to assist patients with cognitive impairment to conduct the interviews .
this study found that the quality of care , from the perspective of hf patient / caregiver experiences and preferences , was not optimal .
the survey identified many care gaps both within gmu and with the dc summary hand - off .
the first step in this program is to perform a root cause analysis to determine the source of these quality gaps .
the second step is an organization change to move the dc summary implementation via a cardiogeriatric clinic to gmu to provide direct performance feedback .
the root cause analysis and this direct dc summary implementation feedback will provide input to drive the necessary process re - engineering . in this and similar cardiogeriatric settings ,
the key is to provide a clinical framework that allows the cardiologist , geriatrician , pcp , patient , and caregiver to actively work together as a team to develop the optimal dc plan .
 backgroundevidence indicates that care experiences for complex hf patients could be improved by simple organizational and process changes , rather than complex clinical mechanisms . 
 this survey identifies care gaps and recommends simple changes.methodsthe study utilized both quantitative and qualitative methods at the ottawa hospital , geriatric medical unit ( gmu ) during a three - month period.resultsnineteen patients ( average age 85 , 12 female ) surveyed . 
 twelve participants lived alone . 
 fourteen lived in own home . 
 four patients had formal home - care services . 
 fifteen relied on family . 
 gaps were identified in in - patient practice , discharge plan , and discharge summary implementation feedback . 
 only five participants had seen a cardiologist or a specialist . 
 half of the patients did not know if they were on a special heart - failure ( hf ) diet . 
 participants did not recall receiving information on life expectancy but were comfortable discussing eol care and dying . 
 hf - specific management recommendations were mentioned in only 37% of discharge summaries to primary care providers ( pcps).conclusionthe results provide the starting point for a quality assurance and process re - engineering program in gmu . 
 organization change is needed to develop and integrate a cardiogeriatric clinical framework to allow the cardiologist , geriatrician , and pcp to actively work as a team with the patient / caregiver to develop the optimal care plan pre- and post - discharge . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
GMU Items
Patient/Caregiver Items
Limitation of Our Survey
CONCLUSION/FUTURE DIRECTION