Providers team up to cut HF readmissions

Area of Science:

• Clinical Care Coordination
• Heart Failure Management
• Healthcare Systems Integration

Background:

• Heart failure readmissions pose a significant challenge to healthcare systems.
• Effective care coordination is crucial for managing chronic conditions like heart failure.

Purpose of the Study:

• To describe the role and impact of a clinical integration case manager serving as a heart failure liaison.
• To evaluate the effect of this role on patient readmission rates.

Main Methods:

• A clinical integration case manager was embedded within the Hartford Physician Hospital Organization.
• The liaison coordinated care between hospital, physician associations, home health, and skilled nursing facilities.
• Direct patient engagement occurred during hospitalization and post-discharge via phone contact.

Main Results:

• The heart failure liaison initiative maintained a stable readmission rate between 11% and 13%.
• Referrals were primarily received during physician rounds, indicating integration with clinical teams.
• Ongoing collaboration with post-acute care providers ensured patient needs were met.

Conclusions:

• A dedicated heart failure liaison can effectively coordinate complex patient care.
• This role contributes to stabilizing readmission rates by bridging care transitions.
• Integrated case management is a viable strategy for improving heart failure patient outcomes.