Symptom-driven network care for frail older patients with heart failure in primary care (FRAIL-HF)

Heart failure is a chronic progressive syndrome leading to an increased risk of hospital (re)admissions. Notably the management of older patients is complex; around 80% have 3 or more chronic diseases, 50% of them are frail, and 40% have cognitive problems. This makes their management challenging. Hospital care is often 'crisis management', because the underlying root causes of their frailty cannot be adequately managed during the short duration of an admission. This easily results in repeated (re)admissions, because at discharge patients are stabilized, but not yet stable. 

AIM and approach

The aim of this project is to improve the quality of life of frail older people with heart failure and prevention of readmissions. We develop and evaluate a proactive person-centered home-based care model, based on interprofessional collaboration and aligned with hospital care.