Cardiac Care Bridge trial

After a hospital admission for heart disease, older patients are at high risk of adverse outcomes such as readmission and death. The current treatment in older cardiac patients is focused on disease management while less attention is paid to general healthcare needs. In the Cardiac Care Bridge (CCB) program we aim to examine the effectiveness of a nurse-coordinated transitional intervention including case management, cardiovascular risk management and home-based rehabilitation for older cardiac patients at high risk of functional loss.

With the Cardiac Care Bridge trial, we hypothesize a 12.5% absolute risk reduction on the composite endpoint of first all-cause unplanned hospital readmission or mortality within six months after randomization.

The primary outcome will be measured at six months. Secondary outcomes will be measured at three months (phone), six months (home visit) and twelve months (phone)

Patients admitted to the department of cardiology or cardiac surgery of > 70 years, at high risk of functional loss and admitted > 48 hours are eligible for inclusion. The program combines case management, disease management and home-based cardiac rehabilitation. All participants will receive a comprehensive geriatric assessment (CGA), performed by a cardiac nuse. Participants in the intervention group will receive care based on identified problems from the CGA in three phases.

1.In the clinical phase, an integrated care plan will be established for all participants. The department of geriatrics will be consulted in case of at least 1 identified problem on the psychological domain or minimal 5 identified geriatric problems in general.

2. In the transitional phase, before discharge, a coordinating community care registered nurse (CCRN) visits the participant in the hospital to receive a face-to-face handover from the cardiac nurse.

3. The post-clinical phase consists of four home visits by the CCRN to continue care based on the integrated care plan, including cardiovascular risk management and evaluation of participants' health status. The CCRN works in close collaboration with the physiotherapist, who will perform nine home-based cardiac rehabilitation sessions to improve participants' functional status.