The role of continuous care in reducing readmission for patients with heart failure

About 20-50% of patients with heart failure are readmitted to hospitals in 14 day to 6 months of hospital discharge. Several supportive programs are developed to reduce post discharge hospital readmissions. The present study was performed to review the clinical trials conducted to determine the effect of post-discharge follow-up on readmission of patients with heart failure (HF).

Internet search was conducted to identify clinical trial studies that have been conducted on post-discharge follow-up care for patients with HF. Databases of Science direct, Pubmed, Iranmedex, SID and also the Google's search engine were searched for studies that have been published between the years 1995 and 2013. Keywords used in searching Persian databases were included readmission, heart failure, continuous care, and follow-up. Keywords used in searching English databases were included of heart failure, readmission, follow-up and home monitoring.

21 clinical trials were reviewed. 16 studies have shown that continuous care through patient education before discharge, home visits, and telephone follow up could significantly reduce the rate of post discharge readmissions of patients with HF. However, five studies did not show significant reductions in post-discharge readmissions.

Patient education and continuous post-discharge follow up interventions conducted by nurses could significantly reduce the rates of readmissions to the hospital or to the physicians' office. Considering limited health care resources, using one or a combination of follow-up methods, can reduce the number of readmissions of patients with HF.