---
title: Reducing Readmission for Frail Elderly Patients With Decompensated Heart Failure
nct_id: NCT03246035
overall_status: COMPLETED
phase: NA
sponsor: Jewish General Hospital
study_type: INTERVENTIONAL
primary_condition: Heart Failure
countries: Canada
canonical_url: "https://parkinsonspathways.com/agent/trials/NCT03246035.md"
clinicaltrials_gov: "https://clinicaltrials.gov/study/NCT03246035"
ct_last_update_post_date: 2022-10-14
last_seen_at: "2026-05-12T07:34:39.766Z"
source: ClinicalTrials.gov (mirrored, no enrichment)
---
# Reducing Readmission for Frail Elderly Patients With Decompensated Heart Failure

**Official Title:** A Prospective Randomized Pilot Trial to Reduce Readmission for Frail Elderly Patients With Acute Decompensated Heart Failure

**NCT ID:** [NCT03246035](https://clinicaltrials.gov/study/NCT03246035)

## Key Facts

- **Status:** COMPLETED
- **Phase:** NA
- **Study Type:** INTERVENTIONAL
- **Target Enrollment:** 60
- **Lead Sponsor:** Jewish General Hospital
- **Collaborators:** Canadian Association of Emergency Physicians
- **Conditions:** Heart Failure, Acute Decompensated Heart Failure, Fragility, Emergencies
- **Start Date:** 2018-03-01
- **Completion Date:** 2022-03-01
- **CT.gov Last Update:** 2022-10-14

## Brief Summary

A randomized study designed to determine whether telephone based interventions can prevent return hospital visits for elderly and frail patients with acute symptoms of heart failure. Specifically, the intervention will improve patients ability to monitor and address self care of heart failure at home.

## Detailed Description

Acute decompensated heart failure (ADHF) is a common illness in Canadian emergency departments (ED). The frail subset of elderly patients with ADHF is challenging to treat, use a large proportion of available resources, and are at higher risk for complications, including readmission to hospital after discharge. The investigators believe that by improving access to follow-up, optimizing self-care, and addressing the various cognitive and physical limitations of frailty, it will be possible to improve quality of life and reduce readmission rates for frail patients with ADHF.

## Eligibility

- **Minimum age:** 65 Years
- **Sex:** ALL
- **Healthy Volunteers:** No

```
Inclusion Criteria:

* Patients who presented to the ED and who are being discharged with a primary or secondary diagnosis of ADHF
* Age ≥ 65
* Frailty, defined as a FRAIL score \>=3/5 or Clinical Frailty Scale (CFS) score \>=5/9
* Informed consent provided by the patient or proxy

Exclusion Criteria:

* Significant dementia or active delirium
* Severe frailty, defined as a CFS score \>=8/9
* Prohibitive language barrier
* Primary address outside of Quebec
* Patient deemed to be palliative or moribund by treating team
```

## Arms

- **Control Group (Standard Care)** (ACTIVE_COMPARATOR) — The control group will receive outpatient follow-up, medication advice and lifestyle guidance as prescribed at discharge from the ED or hospital.
- **Intervention Group** (EXPERIMENTAL) — The intervention will consist of contacting the patient 5 days post-discharge and arranging definitive outpatient follow-up and providing targeted medical and lifestyle advice based on deficient domains identified at baseline.

## Interventions

- **Intervention Group** (BEHAVIORAL) — For the intervention arm, a specialized heart failure nurse practitioner will contact the patient or their primary caregiver by telephone within 5 days post-discharge and send them an education packet by mail. During the telephone call, the nurse will (1) confirm the patient's scheduled follow-up appointment in cardiology, (2) provide recommendations for heart failure self-care behaviors that were found to be deficient at baseline. Patients will then be referred to a Geriatrics Assessment Team, who will provide individualized recommendations for frailty domains that were found to be deficient at baseline. The technique used to provide educational recommendations will be motivational interviewing.
- **Control Group (Standard Care)** (OTHER) — For patients randomized to the Control Group (Standard Care), they will receive their follow-up visits, medications, diet and physical activity advice as they normally would. This is the care they would receive even if they were not enrolled in the study

## Primary Outcomes

- **All-cause death, hospital readmission, or ED revisit** _(time frame: 90 days)_

## Secondary Outcomes

- **Rate of return visits to any ER for any medical issue** _(time frame: 30 days)_
- **Rate of admission to hospital at 90 days** _(time frame: 90 days)_
- **Incidence of adverse effects from medication** _(time frame: 90 days)_
- **Self-Care Index** _(time frame: 90 days)_
- **Heart Failure Symptom Scale** _(time frame: 90 days)_
- **Frailty Index** _(time frame: 90 days)_
- **Recruitment rate** _(time frame: 90 days)_
- **Attrition rate** _(time frame: 90 days)_
- **Informed consent validation (qualitative)** _(time frame: 90 days)_
- **All-cause death, hospital readmission, or ED revisit** _(time frame: 1 year)_

## Locations (1)

- Jewish General Hospital, Montreal, Quebec, Canada

## Recent Field Changes (last 30 days)

- `sponsor.lead` — added _(2026-05-12)_
- `sponsor.collaborators` — added _(2026-05-12)_
- `results.hasResults` — added _(2026-05-12)_
- `locations.jewish general hospital|montreal|quebec|canada` — added _(2026-05-12)_
- `status.overallStatus` — added _(2026-05-12)_
- `status.primaryCompletionDate` — added _(2026-05-12)_
- `status.completionDate` — added _(2026-05-12)_
- `status.lastUpdatePostDate` — added _(2026-05-12)_
- `design.phases` — added _(2026-05-12)_
- `design.enrollmentCount` — added _(2026-05-12)_
- `eligibility.criteria` — added _(2026-05-12)_
- `eligibility.minAge` — added _(2026-05-12)_
- `eligibility.sex` — added _(2026-05-12)_
- `outcomes.primary` — added _(2026-05-12)_
- `outcomes.secondary` — added _(2026-05-12)_
- `armsInterventions.arms` — added _(2026-05-12)_
- `armsInterventions.interventions` — added _(2026-05-12)_

---

*Canonical: https://parkinsonspathways.com/agent/trials/NCT03246035.md*  
*Source data (authoritative): https://clinicaltrials.gov/study/NCT03246035*  
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