Implementation of early follow-up care after heart failure hospitalization.

Objectives: The evidence supporting early postdischarge hospital follow-up is limited. We implemented a new, multidisciplinary, multistrategy heart failure (HF) team approach that included new clinic slots, predischarge nurse visit, providing a blood pressure cuff and scale, and cardiologist supervision.

Study Design: Pre- vs postintervention evaluation of outcomes in patients hospitalized with HF between September 1, 2010, and May 30, 2013. We utilized the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework to evaluate the intervention.

Methods: For the quantitative evaluation, we compared the proportion of patients in both groups who were scheduled for and completed a cardiology appointment within 7 days after hospitalization ("reach"). We created a Cox model to evaluate the "effectiveness" of the intervention period on a 30-day composite outcome (all-cause emergency department [ED] visit, all-cause hospitalization, or death). In qualitative evaluation, we describe the adoption, implementation, and maintenance of the intervention.

Results: Data for 261 patients were analyzed (preintervention, n = 142; post intervention, n = 119). The postintervention period was associated with a higher proportion of patients who were referred to (40% vs 12%; P < .001) and completed (24% vs 10%; P = .003) cardiology follow-up within 7 days of hospital discharge (reach) compared with the preintervention period. After adjustment, the postintervention period was associated with a reduced hazard of the 30-day composite end point (HR, 0.59; 95% CI, 0.37-0.96; P = .04) (effectiveness).

Conclusions: The intervention succeeded in increasing referral to and completion of cardiology appointments within 7 days of discharge. In adjusted analysis, the intervention was associated with lower risk of 30-day all-cause ED visits, all-cause hospitalizations, or death.