Discharge Planning in Emergency Department for Frail Older With AHF

• All-cause emergency revisit rate[ Time Frame: at 30 days post-discharge ]
  The proportion of patients who have ED revisit for all causes within 30 days after discharge
• Acute heart failure emergency revisit rate[ Time Frame: at 30 days post-discharge ]
  The proportion of patients who have ED revisit for acute heart failure within 30 days after discharge
• Cardiovascular emergency revisit rate[ Time Frame: at 30 days post-discharge ]
  The proportion of patients who have ED revisit for cardiovascular event within 30 days after discharge
• All-cause hospitalisation rate[ Time Frame: at 30 days post-discharge ]
  The proportion of patients who have an hospitalisation for all causes within 30 days after discharge
• Acute heart failure hospitalisation rate[ Time Frame: at 30 days post-discharge ]
  The proportion of patients who have hospitalisation for acute heart failure within 30 days after discharge
• Cardiovascular hospitalisation rate[ Time Frame: at 30 days post-discharge ]
  The proportion of patients who have hospitalisation for cardiovascular events within 30 days after discharge
• All-cause mortality rate[ Time Frame: at 30 days post-discharge ]
  The proportion of patients who have all-cause mortality within 30 days after discharge
• Cardiovascular mortality rate[ Time Frame: at 30 days post-discharge ]
  The proportion of patients who have cardiovascular mortality within 30 days after discharge
• Free-hospitalization survival[ Time Frame: at 30 days post-discharge ]
  Number of days alive out of the hospital
• Functional impairment (assessed by self-reported Barthel index)[ Time Frame: Change from baseline to 30 days post-discharge ]
  Barthel index measures the subject's capacity to perform ten activities of daily living (feeding, bathing, grooming, dressing, bowel and bladder control, toileting, chair transfer, ambulation and stair climbing). The sum score ranges from 0 (totally dependent) to 100 (totally independent).
• Pharmacological adherence (assessed by Morisky Medication Adherence Scale)[ Time Frame: Within 30 days after discharge ]
  The four-item MGLS measures pharmacological adherence. The score ranges from 0 (perfect adherence) to 4 (some level of non-adherence).
• Satisfaction of patient or caregiver about transition of care (assessed by Care Transitions Measure questionnaire)[ Time Frame: Within 30 days after discharge ]
  CTM questionnaire assesses the quality of care transitions, with lower scores indicating a poorer quality transition, and higher scores indicating a better transition.
• Quality of live of patients (assessed by EuroQol-5D)[ Time Frame: Within 30 days after discharge ]
  EQ-5D measures of health-related quality of life. The descriptive system comprises 5 dimensions (mobility, self care, usual activities, pain/discomfort, anxiety/depression) and each dimension has 5 levels (no problems, slight problems, moderate problems, severe problems, and extreme problems). The EQ VAS records the respondent's self-rated health on a 20 cm vertical, visual analogue scale with endpoints labelled 'the best health you can imagine' and 'the worst health you can imagine'.

Objectives: To demonstrate the efficacy of care transition holistic intervention (Multilevel Guided Discharge Planning, MGDP) in reducing 30-day adverse outcomes among frail older patients with acute heart failure (AHF) discharged from Emergency Departments (EDs) and to validate the results of MGDP in real life. Method: Investigators will select frail patients ≥70 years with primary diagnosis of AHF discharged from EDs. The intervention will consist of MGDP implementation: 1) checklist that includes clinical recommendations and resources activations; 2) scheduling of early visit with the specialist; 3) communication with primary care; 4) providing a written instruction sheet to patient or caregiver. Phase 1: matched-pair cluster randomized clinical trial. EDs were randomly allocated to intervention (n = 10) or control (n = 10) group. Investigators will compare the outcomes between intervention and control groups. Phase 2: a quasi-experimental study. The 20 EDs will carry out the intervention. Investigators will compare the outcomes between phase 1 and phase 2 of intervention group and between phase 1 and phase 2 of control group. The main outcome is a 30-day composite endpoint (ED revisit or hospital admission for AHF and cardiovascular death) after being discharged.

• Other: Multilevel Guided Discharge Planning
  Clinical recommendations and resources activations + scheduling of early visit with the specialist + communication with primary care + written instruction sheet to the patient
• Other: Standard of care
  Standard of care

• Experimental: Multilevel Guided Discharge Planning
• Active Comparator: Standard of care