A multidisciplinary transition of care approach to reduce 30-day readmissions in heart failure patients.

Background: While advancements in pharmacologic and device therapies have improved survival, one in five adults with heart failure (HF) patients is readmitted within 30 days of discharge. Thus, the epidemic of HF is largely one of increasing hospitalizations.

Objective: To determine if a comprehensive HF program reduces 30-day readmission rate.

Methods: A convenience sample of adults with Medicare and HF (N = 1617) admitted to a large academic medical center were identified. Patients received HF education by a specialized registered nurse while inpatient and were seen by a pharmacist prior to discharge. Post-discharge, patients were called by a pharmacist within 72 h, followed by an ambulatory care manager for 90 days, and scheduled for a multidisciplinary clinic visit with a nurse practitioner within 7 days of hospitalization. High risk patients were referred to a community health worker (CHW). Clinic services included phlebotomy, education, point-of-care ultrasound, intravenous diuretic administration, and referrals to appropriate services. Data were analyzed descriptively.

Results: The 30-day readmission rate was 18.39 % (N = 930) during the intervention period compared to 22.71 % (N = 617) at baseline, resulting in a 4.32 % reduction, p value 0.0325. Approximately 40 percent of the patient cohort was over age 85. Pharmacy was able to contact greater than 86 % of patients post discharge. Only half of patients were agreeable to ambulatory care management. Less than half (42 %) of eligible patients were seen in the post-discharge clinic. The CHW supported approximately 146 patients in a 9-month period.

Conclusions: A real-world comprehensive multidisciplinary team approach to the management of HF patients can reduce 30-day hospital readmissions.