Implementing a Heart Failure Transition Program to Reduce 30-Day Readmissions

Abstract

Background: Thirty-day readmissions for heart failure (HF) patients are often considered avoidable and linked to inadequate treatment and poor coordination of services and discharge plans. Problem: Lack of coordinated transitional care services and high 30-day readmissions prompted the interdisciplinary team to develop an HF Transition Program (HFTP). Methods: This quality improvement initiative used monthly trend data before and after HFTP implementation. Interventions: The American Heart Association Guidelines for HF Transitions served as a framework for developing the HFTP. Results: Over an 11-month period, 466 patients were enrolled into the HFTP, resulting in 18.2% (n = 82/450) 30-day cumulative readmission rate that is lower than the 21.9% national average. Sixteen patients did not code for HF after discharge. Heart Failure Transition Program calls to patients and families within the first week home were consistently high at 92.3% (430/466). Conclusions: These data show that care coordination and transitional care are important strategies to decrease 30-day HF readmissions.

Leading Multisector Partnerships to Address Social Determinants of Health and Advance Health Equity for an Underresourced Heart Failure Patient Population

“…12 Strategies to reduce heart failure readmissions are varied across health systems and are challenging, at best. [13][14][15][16][17][18] Along with a few others, we have found the IPCP model to be an important component to our success. 12,19,20 Providing multimodal interventions including relationship building, provision of resources, education, and coaching, we have achieved sustained reductions in hospital readmissions.…”

Assuring a Continuum of Care for Heart Failure Patients Through Postacute Care Collaboration

“…Key takeaways for the case management practice is to build a robust case management program spanning postacute care facilities, evidence-based treatment protocols, and infrastructure that supports seamless information sharing between sites. Case managers can ensure efficient flow of patient information by adopting innovative health information technology and ensuring information quality is maintained when referrals are placed for transitions (Hinch & Staffileno., 2021). They are better positioned to identify patients at risk for poor transitions and match their needs to an appropriate discharge setting (Adler-Milstein et al, 2021; Boykin et al, 2018; Samal et al, 2016).…”

“…Collaboration among HF specialists, including advanced practice providers, registered nurses, primary care physicians (PCPs), pharmacists, and case managers, has been shown to reduce the 30-day HF readmission rate (Boykin et al, 2018; Driscoll et al, 2016; Hinch & Staffileno., 2021; Jepma et al, 2021; Naylor et al, 2018; Raat et al, 2021; Radhakrishnan et al, 2018; Summers & Atav, 2020). Driscoll et al (2016) conducted a systematic review of 29 studies, 10 of which were randomized control trials.…”

Ações em saúde propostas em programas de transição do cuidado para idosos: revisão integrativa

“…Nesse enfoque, ao pensar na estruturação de Programas de Transição de Cuidados, voltados para idosos hospitalizados, observou-se concordância entre os autores (Hinch et al, 2021;Poelzl et al, 2021;Gilbert et al, 2021;Crannage et al, 2020;Neu et al, 2020;Baecker et al, 2020;Vearing et al, 2019;Wu et al, 2019;Warren et al, 2019;Huckfeldt et al, 2019;Murphy et al, 2019;Finlayson et al, 2018;Ballard et al, 2018;Robertson et al, 2018;Hanan et al, 2018;Iseler et al, 2018;Low et al, 2017;Takahashi et al, 2016;Heim et al, 2016;Wong et al, 2016;Morrison et al, 2016;Lovelace et al, 2016;Zhou et al, 2015;Low et al, 2015;Mae et al, 2014;Wee et al, 2014;Cheng et al, 2014;Logue et al, 2013;Kind et al, 2012;Shu et al, 2011;Stauffer et al, 2011;Ornstein et al, 2011;Daley et al, 2010) acerca do impacto positivo desses programas, principalmente no que tange à redução das taxas de reinternação hospitalar em até 30 dias (Hinch & Staffileno, 2021;Gilbert et al, 2021;Crannage et al, 2020;Wu et al, 2019;Warren et al, 2019;Huckfeldt et al, 2019;Low et al, 2017;…”