Reducing Heart Failure Readmission Through Collaboration: An Acute Care and Post-Acute Success Story

Heart failure (HF) is one of the most common diagnoses in the United States during hospitalization. The incidence of HF is expected to increase in the future, coinciding with the expected increase in the utilization of post-acute care facilities. Recent studies have demonstrated that the implementation of an original Heart Failure Disease Management Program (HFDMP) has a significant potential to decrease readmissions. The Department of Internal Medicine at two acute care hospitals coordinated with a post-acute facility for the implementation of an HFDMP quality improvement project.

The interdisciplinary team developed the HFDMP, which included formalized training for the entire resident care staff, redesigning the post-acute facility's dietary manual, strengthening the postdischarge appointments workflow, creating a dedicated HF unit, identifying additional patient care supplies needed to care for residents with HF, and identifying metrics to monitor after implementation to determine success.

Before the implementation of the program, the 30-day readmission rate of the HF hospital was 20%. After implementation, only one resident was readmitted for non-HF-related conditions, corresponding to a 30-day readmission rate of 2.78%.

The implementation of similar HFDMPs at post-acute care facilities across the country represents a significant opportunity to decrease 30-day readmissions and improve resource utilization.