Heart Failure Readmissions and Dedicated Inpatient Coordinator-Led Transitional Care

Congestive heart failure (CHF) is a leading cause of adult hospitalization, with 30-day readmission rates remaining disproportionately high at approximately 25% despite medical advances.

Transitional-care interventions are critical for bridging the gap between inpatient and outpatient settings. Real-world data are necessary to validate the efficacy of dedicated CHF coordinators and guide resource allocation.

A retrospective cohort study evaluated 11,269 adults admitted with acute decompensated CHF from January 2020 through October 2025. Comparing patients receiving a coordinator consultation to a control group, the intervention reduced the odds of 30-day all-cause readmissions by 92% and CHF-specific readmissions by 91%. At 90 days, the reductions were 88% and 85%, respectively.

Inpatient consultation by a dedicated CHF coordinator significantly reduces 30-day and 90-day readmissions. Integrating this role into standard workflows improves long-term outcomes.