Transitional Care Home Visits Among Underserved Patients With Heart Failure

Area of Science:

• Cardiology
• Public Health
• Healthcare Management

Background:

• Heart failure (HF) affects 26 million globally, significantly reducing quality of life.
• Depression is three times more prevalent in HF patients than the general population.
• Transitional care is evidence-based for improving functional status and depression in HF.

Purpose of the Study:

• Evaluate health outcomes in underserved HF patients using a transitional care home visitation program.
• Assess the impact of home visitation timing on patient outcomes.
• Demonstrate leadership's role in healthcare transitions.

Main Methods:

• Retrospective review of 79 underserved HF patients over 2 years.
• Compared outcomes over 6 months post-discharge.
• Analyzed differences between home visits received >14 days versus ≤14 days after discharge.

Main Results:

• Clinically significant differences in health outcomes observed between groups.
• Outcomes favored patients receiving home visits >14 days post-discharge, though not statistically significant.
• The program highlights opportunities for enhanced transitional care.

Conclusions:

• Home visitation programs can improve care for underserved HF patients.
• Further evaluation is needed to optimize transitional care coordination.
• Data from ongoing evaluation can inform patient- and family-centered care strategies.