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Advanced Heart Care at Home

Advanced Heart Care at Home


End-of-life (EOL) care for heart failure (HF) patients is linked to high healthcare utilization and costs, in part due to the lack of integration of optimal HF management and home-based palliative care. The research team demonstrated decreased healthcare utilization and costs and increased hospice utilization among seriously ill HF patients in a pilot quality improvement project of clinician “nudges" (communication techniques that influence choices in a predictable direction without limiting options) to enroll patients in Advanced Heart Care at Home (AHCAH). The AHCAH program is a home-based, integrated HF and palliative care platform that includes specialized nursing assessments, telemedicine monitoring, phone support, medication management, coordination with patients' cardiologists, and a palliative care nurse practitioner who can discuss goals of care and advanced care planning. This pragmatic randomized trial for clinicians of seriously ill HF patients admitted to three University of Pennsylvania Health System Hospitals will randomly assign an opt-in approach (usual care) versus a “nudge” or opt-out approach of a visit from an AHCAH liaison to clinicians of eligible patients to discuss and enroll in the AHCAH program. The goal of this project is 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.


  • Haas

Study Status

Data Collection/Active Recruitment

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