Performance Improvement to Decrease Readmission Rates for Patients With a Left Ventricular Assist Device.

Area of Science:

• Cardiology
• Heart Failure Management
• Medical Device Technology

Background:

• High 30-day readmission rates (32.1%) for left ventricular assist device (LVAD) patients were observed at a major urban hospital.
• Identified need to improve care transitions for LVAD patients based on readmission reviews and patient/family expectations.

Purpose of the Study:

• To evaluate the effectiveness and feasibility of a transitional care model (TCM) for LVAD patients.
• To decrease readmission rates through enhanced self-management skills and care coordination.

Main Methods:

• Implementation of a pilot program in June 2015 involving ten LVAD patients.
• Utilization of a dedicated transitional care nurse (TCN) to facilitate patient flow and collaborate with the ventricular device team.
• Development of individualized care plans focused on improving patient self-management skills.

Main Results:

• The 30-day readmission rate decreased to 14.3% during the pilot phase.
• This represents a significant reduction compared to the previous annual overall readmission rate of 42.6%.

Conclusions:

• The transitional care model (TCM) demonstrated effectiveness in reducing readmissions for LVAD patients.
• Further research into TCM-consistent interventions is recommended to advance care coordination and facilitate transitions for this vulnerable patient group.