Introduction: A large Midwest Academic Medical Center is not at their predicted rate of readmission for heart failure (HF). We describe the development of a heart failure transition program (HFTP) comprised of the components recommended by the 2015 AHA Scientific Statement on Transitions of Care in Heart Failure.
Methods: The HFTP was formed to help reduce HF readmissions. The HFTP is an integrated, interdisciplinary team that utilizes home health agencies (HH), social work outreach, daily phone communication and e-mails. These systematic strategies for communication amongst the team allow for follow up ensuring patients are evaluated throughout the continuum of care. In addition, monthly analysis of possible missed opportunities to prevent readmissions is evaluated by the team. Intensive front loading of services at home during the first week post discharge is key in this model: 24-hour medication reconciliation, home health visits, transitional care management call (TCM), social worker call, and aggressive screening for barriers to care.
Results: The hospital readmission rate for HF has decreased from 24.5 % in FY16 to 20.4% in FY17. From Nov. 2016 - Mar. 2017 there have been 242 patients seen by the HFTP and 46/242 were readmitted within 30 days which is a readmission rate of 18.98%. Of those readmitted, 68% were HF and 32% were non-HF; 90% of patients left with HF clinic appointment in 7-10 days however only 48% attended that appointment. Patient data: average age 66 years, 91% HTN, 50% have CAD, CKD or DM; 57% are Medicare/Medicaid, 38% private insurance and 5% uninsured; 52% of patients were discharged without HH, 38% went home with HH and 10% were discharged to a SNF. Program process outcomes include: 92% received an inpatient psychosocial evaluation; 92% received a follow up TCM call within 72 hours and 77% received social worker follow up call within 1 week post discharge.
Conclusion: The HFTP connects inpatient care to the post-acute care team in the ambulatory and community setting which is unique in this model. Based on data to date, this model is effective for care coordination to help achieve the hospitals overall HF goals.