Data-driven development of a model for home care in advanced heart failure, supported by user experience design and telemedicine

Research problem and specific questionsPatients with end-stage heart failure (HF) frequently undergo repeated hospitalizations as a standard practice but would most likely benefit more from home care.

Half of hospitalizations occur during the last 2 months prior to death at a state when acute treatment is limited to palliative measures.

Remote patient monitoring, including telemonitoring, is increasingly incorporated into clinical routine and its advantages in HF gradually acknowledged.

The overall aim of this proposal is to provide an alternative to the present routine care of repeated unplanned hospitalizations: Can we create a safe and cost-effective model for remote patient management and telemonitoring, including specialized clinical competence available around-the-clock, for advanced/end-stage HF home care?Data and methodWe plan to create a customized model of home care in advanced/end-stage HF using data from electronic health records for a data driven approach to identify patients from a large database of 40 000 patients who have been hospitalized in Region Västra Götaland 2012-2023.

First, prognostic modeling for identification of suitable patients will be developed using statistical and machine learning methods.

A model for home care in HF will be co-created through user experience (UX) design via workshops, interviews and focus groups with stakeholders, including patients and care personnel.Societal relevance and utilizationTreatment of advanced HF constitutes a key challenge concentrated among the elderly.

Our goal is to enhance the patient´s quality of life, delivering person centered, safe and satisfying care in a home setting.

If the model is successful, it can be implemented in clinical practice in Swedish palliative health care for a larger group of patients.Plan for project realizationThe project realization will include design of fundamental organizational and medical requirements and UX design covering: 1) patient identification model from health data applying data science methods, 2) construction of patient and collaborator journeys, 3) referral and inclusion process, 4) requirements for staffing and medical competencies, 5) person centered care, 6) limitations against other care processes, 7) administrative support and software requirements.

The goal of this proposal is to present a finalized product to launch for application as an intervention to compare the process for specialized home care with regular standard of care.