The St. Vincent’s Free Congestive Heart Failure Comprehensive Care Clinic: A Community-Based Intervention and Analysis

Abstract

Introduction: Post-hospitalization heart failure (HF) disease management represents an important area of focus in preventing morbidity, mortality, and excess healthcare costs. Disease management clinics have been historically successful in reducing complications, but complication reduction in the uninsured setting has not been thoroughly examined. The purpose of this project is to conduct a post-hospitalization disease management clinic pilot study of uninsured HF patients. Methods: This is a pilot study of HF patients following a recent hospitalization (within 30 days). Uninsured patients were offered enrollment in the disease management clinic during or immediately following hospitalization for a primary HF diagnosis at University of Texas Medical Branch at Galveston. The enrollment period was from January 2021 - December 2021. The disease management program included twice-weekly visits with a variety of healthcare professionals, including nurses, physicians, occupational therapists, social workers, pharmacists, and counselors. Patients were scheduled for a maximum of 16 visits (2 months of follow-up) post-hospitalization before returning to usual care. Patients who attended at least the introductory appointment and one follow-up appointment within 30 days of discharge were considered enrolled. The primary outcome is 30-day readmission, while secondary outcomes included feasibility measures (proportion enrolled, number of visits attended). Results: Of 59 patients referred, 47 (80%) were enrolled. Just 4 patients (8.5%, 95% CI: 2.5%, 20.5%) were readmitted at 30 days, while 4 of 12 (33%, 95% CI: 13.6%, 61.2%) were readmitted at 30 days in those who did not enroll. Program participants were readmitted significantly less frequently than national readmission rate estimates (23%, p=0.02). Conclusion: The CHFC3 program is feasible and holds promise for materially reducing 30-day readmissions for HF complications in the uninsured. A randomized controlled trial is warranted to further explore this intervention.