Targeting the Correct Population When Designing Transitional Care Programs for Medicare Patients Hospitalized With Heart Failure

Ahmad, Faraz; Wehbe, Ramsey M.; Kansal, Preeti; Jackson, Hannah Alphs; Anderson, Allen S.; Yancy, Clyde W.; Mutharasan, R. Kannan

doi:10.1001/jamacardio.2017.3089

Cited by 6 publications

(3 citation statements)

References 3 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…More advanced strategies, such as screeners based on brain natriuretic peptide (BNP) levels and administration of intravenous diuretics, can be employed. 14,15 In the near future, deep learning-based natural language processing will be applied to mine fulltext data in the electronic health record to identify heart failure hospitalizations. 16 In the hospital, patients can also receive education about heart failure disease management.…”

Section: During Hospitalizationmentioning

confidence: 99%

“…We deployed this query, finding very high sensitivity for detection of heart failure patients. 14 Patients found to have heart failure were then populated into a list in the electronic health record, which made patients' heart failure status visible to all members of the health care team. Using this list, we were able to automate several processes necessary for heart failure care.…”

Section: Process Of Process Improvement: Our Experiencesmentioning

confidence: 99%

See 1 more Smart Citation

The Role of Process Improvements in Reducing Heart Failure Readmissions

Dong¹

2020

JCOM

View full text Add to dashboard Cite

Objective: To review selected process-of-care interventions that can be applied both during the hospitalization and during the transitional care period to help address the persistent challenge of heart failure readmissions. Methods: Review of the literature. Results: Process-of-care interventions that can be implemented to reduce readmissions of heart failure patients include: accurately identifying heart failure patients; providing disease education; titrating guideline-directed medical therapy; ensuring discharge readiness; arranging close discharge follow-up; identifying and addressing social barriers; following up by telephone; using home health; and addressing comorbidities. Importantly, the heart failure hospitalization is an opportunity to set up outpatient success, and setting up feedback loops can aid in postdischarge monitoring. Conclusion: We encourage teams to consider local capabilities when selecting processes to improve; begin by improving something small to build capacity and team morale, and continually iterate and reexamine processes, as health care systems are continually evolving.

show abstract

Section: During Hospitalizationmentioning

confidence: 99%

Section: Process Of Process Improvement: Our Experiencesmentioning

confidence: 99%

The Role of Process Improvements in Reducing Heart Failure Readmissions

Dong¹

2020

JCOM

View full text Add to dashboard Cite

show abstract

“…In 2015, as part of a multidisciplinary intervention to improve outcomes for hospitalized heart failure patients, we systematically identified all patients within our hospital at risk for heart failure-related readmissions through a daily enterprise data warehouse screen; 4 developed a multidisciplinary bridge and transition team to engage patients during the index hospitalization; and then deployed queuing theory to first assess and then improve clinic follow-up.…”

mentioning

confidence: 99%