Effect of a Post-Discharge Telephone-Based Intervention Led by Social Workers to Reduce Heart Failure Readmissions

Heart failure (HF) readmission rates at our institution were often higher than the expected levels for our institution type. Social work post-discharge telephone calls were identified as an opportunity to address reasons for HF therapy noncompliance, a major reason for readmissions identified among HF patients at our institution.

Our study aimed to improve existing post-discharge telephone outreach performed by social workers to reduce 30-day all-cause readmission rates in traditional Medicare patients with HF at a single academic tertiary care hospital. A multidisciplinary team of social workers, nurses, and physicians created 2 HF-specific forms based on an online resource (Target: HF telephone form) provided by the American Heart Association. The first form focused on HF transition of care-related issues, while the second form focused on HF patient education. These HF-specific forms replaced a generic checklist used by social workers during their post-discharge outreach.

Fifty-one patients were included in the intervention. The mean age was 76.82 years old. Most patients were male (56.9%), White (82.4%), Hispanic (58.8%), and spoke English as their preferred language (54.9%). Pre-intervention, the 30-day all-cause readmission rate ranged from 7.1% to 30.8%. Post-intervention, the 30-day all-cause readmission rate ranged from 8.3% to 25.0%. The pre-intervention mean 30-day all-cause readmission rate was 15.5% with a standard deviation of 8.1%, whereas the post-intervention mean was 16.8% and a standard deviation of 5.3% (P = .721).

HF-specific structured telephone support by social workers post-discharge did not reduce 30-day all-cause readmission rates in an elderly, traditional Medicare population with HF.