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Physician-directed heart failure transitional care program: a retrospective case review
Ken S Ota1, David S Beutler, Richard D Gerkin
1Banner Good Samaritan Medical Center, Department of Transitional Care Medicine, Phoenix, Arizona, USA.
Journal of Clinical Medicine Research
|August 27, 2013
Summary
A hospital-based Heart Failure Transitional Care Program significantly reduced 30-day and 90-day rehospitalization rates for heart failure patients. This physician-directed intervention offers a model for reducing heart failure readmissions.
Area of Science:
- Cardiology
- Healthcare Management
- Patient Care
Background:
- National efforts to improve care transitions for heart failure patients at risk of rehospitalization have yielded limited success.
- Thirty-day rehospitalization rates for heart failure (HF) remain a persistent challenge in healthcare.
Purpose of the Study:
- To evaluate the effectiveness of a physician-directed Heart Failure Transitional Care Program (HFTCP) in reducing patient rehospitalization.
- To assess the impact of the HFTCP on 30-day and 90-day readmission rates.
Main Methods:
- Retrospective review of 73 patients in a hospital-based Heart Failure Transitional Care Program (HFTCP).
- Analysis of 30- and 90-day readmission rates before and after program enrollment.
- Intervention included bedside discharge consultation, home visits, frequent phone calls, education, outpatient diuretic therapy, and 24/7 specialist access.
Main Results:
- Pre-enrollment 30-day readmission rates for acute decompensated heart failure (ADHF) and all-cause were 26.0% and 28.8%, respectively.
- Post-enrollment 30-day rates significantly decreased to 4.1% (ADHF) and 8.2% (all-cause) (P < 0.001 for both).
- Pre-enrollment 90-day rates were 58.9% (ADHF) and 69.8% (all-cause), dropping to 16.4% (ADHF) and 27.3% (all-cause) post-enrollment (P < 0.001 for both).
Conclusions:
- The physician-implemented Heart Failure Transitional Care Program effectively reduced rehospitalization risk in enrolled patients.
- This program serves as a potential model for other healthcare systems aiming to decrease heart failure readmission rates.
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