Implementing a Heart Failure Transition Program to Reduce 30-Day Readmissions

Thirty-day readmissions for heart failure (HF) patients are often considered avoidable and linked to inadequate treatment and poor coordination of services and discharge plans.

Lack of coordinated transitional care services and high 30-day readmissions prompted the interdisciplinary team to develop an HF Transition Program (HFTP).

This quality improvement initiative used monthly trend data before and after HFTP implementation.

The American Heart Association Guidelines for HF Transitions served as a framework for developing the HFTP.

Over an 11-month period, 466 patients were enrolled into the HFTP, resulting in 18.2% (n = 82/450) 30-day cumulative readmission rate that is lower than the 21.9% national average. Sixteen patients did not code for HF after discharge. Heart Failure Transition Program calls to patients and families within the first week home were consistently high at 92.3% (430/466).

These data show that care coordination and transitional care are important strategies to decrease 30-day HF readmissions.