Background: As heart failure (HF) prevalence continues to climb, patient re-hospitalizations challenge collective healthcare resources across the US. Many centers have implemented care transition strategies to reduce 30-day readmissions, but impacting 90-day readmissions and sustaining those positive outcomes remain daunting.
Aim: Create and implement a programmatic structure to embed a care transitions approach to HF patient care at a tertiary care medical center, sustaining reduced patient readmissions and improving the patient care experience.
Methods: To effect change in our evidence-based HF care processes, we adopted a multidisciplinary team approach to develop, implement and monitor patient care processes. Post-discharge phone calls to patients proved a particularly impactful intervention. Weekly internal meetings and monthly meetings with patient and community partner participation were implemented, in addition to ongoing, multimodal communication to the frontline care team to share strategies and outcomes data. Actively engaging patients in care improvement efforts is critical to understanding and meeting their needs and inpatient interviews with empathy mapping was used. Patients participated in medication safety workshops and provided feedback on educational tools that were developed. EMR-embedded tools were created to guide workflows and facilitate analytics (outcomes/balancing measures, process measures, automated risk assessment). Routine team review of post-discharge coding, individual patient readmissions and evaluating program impact on care delivery costs were instituted.
Results: 12 months of data both pre- and post- program implementation, all-cause 90-day readmissions declined by 23% from baseline 31% (160 of 524) to 24% (78 of 327). HF patient subjective reporting of feeling prepared to manage self-care post discharge improved by 6%, while understanding of medications improved by 5%.
Conclusion: Impacting HF readmissions remains challenging. In executing healthcare quality improvement initiatives, implementing programmatic structure in addition to interventions is essential to sustain positive results with manageable resources. Involving the multidisciplinary team, developing community partnerships and engaging patients are key.