A pilot randomized trial of a solution-focused, telehealth-supported transitional care program in older adults with heart failure

Abstract Background Heart failure (HF) is a leading cause of hospitalization among older adults and is associated with poor post-discharge outcomes. Multicomponent transitional care programs incorporating telehealth may improve self-management and care transitions; however, their feasibility and preliminary effects require further evaluation in older adults with HF. This study developed and evaluated a solution-focused, telehealth-supported program (SF-TSTCP) integrating structured transitional care, wearable devices, an online platform, and solution-focused approach during telephone follow-up. Methods A two-phase design was used. Phase I involved qualitative interviews with older adults with HF to inform intervention development. Phase II was a pilot randomized controlled trial conducted in a tertiary hospital in Southwest China. Fifty-six hospitalized HF patients aged ≥ 60 years were randomized 1:1 to transitional care (TC) or usual care (UC). The SF-TSTCP was delivered from admission through 30 days after discharge. Data were collected at baseline (T0, admission), discharge (T1), 30 days after discharge (T2), and 90 days after discharge (T3). Primary outcomes were feasibility and acceptability (including satisfaction with each program component and willingness to continue); secondary outcomes included discharge preparation, transitional care quality, quality of life, and health service utilization. Results Fifty-two participants (92.9%) completed 90-day follow-up. The SF-TSTCP demonstrated high feasibility, with completion rates of 100% for inpatient components, 92.6% for telephone follow-ups, 85.2% for wearable device use, and 70.4% for weekly platform engagement. Participants reported high satisfaction and willingness to continue the program. Compared with UC, the TC group showed improved discharge preparation, transitional care quality, and quality of life at 30 and 90 days after discharge ( p < 0.05 for all comparisons). No significant differences were observed in Unscheduled readmissions, outpatient department visits, or emergency room visits. Conclusions The multicomponent SF-TSTCP was feasible, acceptable for older adults with HF. Preliminary findings suggest potential benefits in discharge preparation, transitional care quality, and quality of life. These findings require confirmation in adequately powered trials.