Advanced Heart Care at Home (AHCAH)

January 22, 2026 updated by: Scott Halpern, University of Pennsylvania

Advanced Heart Care at Home (AHCAH); a Pragmatic Randomized Trial for Clinicians Nudged to AHCAH, a Heart Failure Specific Home Palliative Care Services

End-of-life (EOL) care for heart failure (HF) patients includes high healthcare utilization and costs, in part due to the lack of integration of optimal HF management and home-based palliative care. In a pilot quality improvement project of clinician "nudges" to enroll seriously ill HF patients in a home-based, integrated HF and palliative care platform, the investigators demonstrated decreased healthcare utilization and costs and increased hospice utilization among seriously ill HF patients. The investigators propose a pragmatic randomized trial for clinicians of seriously ill HF patients admitted to three University of Pennsylvania Health System Hospitals, randomly assigning an opt-in approach (usual care) versus a "nudge" or opt-out approach of a visit from an Advanced Heart Care at Home (AHCAH) liaison to clinicians of eligible patients to discuss and enroll in the AHCAH program, to rigorously and scientifically evaluate clinical, utilization, and cost outcomes among high-risk HF patients at the EOL, and to promote physician uptake of best practices.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Other: Clinician nudge or opt out approach for AHCAH liaison visit

Study Type

Interventional

Enrollment (Actual)

709

Phase

Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

United States
- Pennsylvania
  - Philadelphia, Pennsylvania, United States, 191014
    - Perelman Center for Advanced Medicine

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

Description

Inclusion Criteria:

At least 18 years of age
Reside within Caring Way's geographic catchment
Heart Failure ICD code from any previous healthcare encounter (inpatient or outpatient) in the 12 months prior to index hospitalization
Admitted to a cardiology or hospitalist service
Palliative Connect score greater than 0.3
Index hospitalization during study period

Exclusion Criteria:

Less than 18 years of age
Pregnant women
Incarcerated patients
Homeless patients
Reside outside of Caring Way's geographic catchment
Patients without an identifiable primary physician for AHCAH staff to communicate with as determined by the AHCAH liaison via EPIC
Prior hospitalization during study period

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Interventional Model: Parallel Assignment
Masking: None (Open Label)

Number of Arms

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Control Usual Care
Experimental: AHCAH Nudge The investigators have developed methods for sending "nudges" to clinicians via secure text messages to primary teams to alert them that their patient was identified as high-risk for 6-month mortality and that an AHCAH liaison would visit their patient to discuss the AHCAH program and to facilitate enrollment if the patient was amenable. The investigators propose that these secure text messages would be sent to the teams of patients randomized to the intervention by the AHCAH liaison within 72 hours of eligibility identification (to allow for the liaison not being available over the weekend). The investigator team will track all aspects of messaging and timing. Clinicians can choose to opt out a patient from the liaison visit and AHCAH enrollment within a two-hour timeframe.	Other: Clinician nudge or opt out approach for AHCAH liaison visit This study is a "nudge" or opt-out approach of an AHCAH liaison visit to eligible seriously ill HF patients prior to hospital discharge to discuss the AHCAH program and to subsequently facilitate enrolling them in the AHCAH program if they are amenable, compared to the opt-in approach (usual care).

Participant Group / Arm

Intervention / Treatment

No Intervention: Control

Usual Care

Experimental: AHCAH Nudge

The investigators have developed methods for sending "nudges" to clinicians via secure text messages to primary teams to alert them that their patient was identified as high-risk for 6-month mortality and that an AHCAH liaison would visit their patient to discuss the AHCAH program and to facilitate enrollment if the patient was amenable. The investigators propose that these secure text messages would be sent to the teams of patients randomized to the intervention by the AHCAH liaison within 72 hours of eligibility identification (to allow for the liaison not being available over the weekend). The investigator team will track all aspects of messaging and timing. Clinicians can choose to opt out a patient from the liaison visit and AHCAH enrollment within a two-hour timeframe.

Other: Clinician nudge or opt out approach for AHCAH liaison visit

This study is a "nudge" or opt-out approach of an AHCAH liaison visit to eligible seriously ill HF patients prior to hospital discharge to discuss the AHCAH program and to subsequently facilitate enrolling them in the AHCAH program if they are amenable, compared to the opt-in approach (usual care).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Acute care days Time Frame: 6-12 months	number of hospitalization days in the University of Pennsylvania Health System	6-12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mortality Time Frame: 6-12 months	number of patient deaths after enrollment in AHCAH	6-12 months
Hospice enrollment Time Frame: 6-12 months	number of patients who transition from AHCAH to hospice	6-12 months
hospice length of service Time Frame: 6-12 months	If transitioned to hospice from AHCAH, number of days on hospice	6-12 months
University of Pennsylvania Health System total acute care cost Time Frame: 6-12 months	cost of emergency department visit and/or hospitalization within the UPHS Health system	6-12 months
Pennsylvania total acute care cost Time Frame: 6-12 months	cost of emergency department visit and/or hospitalization within Pennsylvania	6-12 months
University of Pennsylvania Health System number of intensive care unit days Time Frame: 6-12 months	number of days hospitalized in an intensive care unit within UPHS	6-12 months
Pennsylvania number of intensive care unit days Time Frame: 6-12 months	number of days hospitalized in an intensive care unit within hospitals in Pennsylvania	6-12 months
University of Pennsylvania Health System emergency department visits Time Frame: 6-12 months	number of emergency department visits within UPHS	6-12 months
Pennsylvania emergency department visits Time Frame: 6-12 months	number of emergency department visits within hospitals in Pennsylvania	6-12 months
Use of intravenous diuretics at home Time Frame: 6-12 months	Prescription and delivery of intravenous diuretics from Penn Home Infusion Therapy Services and administration of intravenous diuretics by AHCAH nurse	6-12 months
new documentation of goals of care Time Frame: 6-12 months	Advance Care Planning documentation within electronic medical record	6-12 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

University of Pennsylvania

Collaborators

Independence Blue Cross

Penn Medicine Center for Health Care Innovation

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

November 13, 2018

Primary Completion (Actual)

October 29, 2024

Study Completion (Actual)

October 29, 2024

Study Registration Dates

First Submitted

October 28, 2018

First Submitted That Met QC Criteria

October 28, 2018

First Posted (Actual)

October 30, 2018

Study Record Updates

Last Update Posted (Actual)

January 26, 2026

Last Update Submitted That Met QC Criteria

January 22, 2026

Last Verified

January 1, 2026

More Information

Terms related to this study

Additional Relevant MeSH Terms

Other Study ID Numbers

831733

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

Studies a U.S. FDA-regulated device product

product manufactured in and exported from the U.S.

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

Advanced Heart Care at Home (AHCAH)