Interprofessional care collaboration for patients with heart failure.

Area of Science:

• Cardiology
• Healthcare Management
• Interprofessional Collaboration

Background:

• Heart failure (HF) poses a significant burden on healthcare systems, often leading to high hospital readmission rates.
• Reducing 30-day hospital readmissions for HF patients is a key objective for healthcare institutions aiming to decrease costs and improve patient outcomes.

Purpose of the Study:

• To describe an innovative collaborative care model designed to enhance transitions of care (TOC) for patients with heart failure (HF).
• To outline the multidisciplinary team's role in preventing 30-day hospital readmissions among HF patients transitioning from hospital to community settings.

Main Methods:

• Formation of an interprofessional team comprising TOC pharmacists, community paramedics, and advanced care practitioners (ACPs).
• Pharmacists provide medication access, reconciliation, and recommendations; paramedics conduct home visits for assessments and education; ACPs offer timely clinic follow-up and long-term HF management.

Main Results:

• The collaborative model facilitates comprehensive post-discharge care coordination for HF patients.
• Integration of diverse healthcare professionals assists in managing HF transitions and potentially reducing readmissions.

Conclusions:

• Collaboration among TOC pharmacists, community paramedics, and ACPs is instrumental in expanding services for HF patients.
• This team-centered, value-based approach supports efforts to reduce avoidable readmissions and healthcare expenditures for heart failure care.