Implementing a Heart Failure Transition Program to Reduce 30-Day Readmissions

Background: Thirty-day readmissions for heart failure (HF) patients are often considered avoidable and linked to inadequate treatment and poor coordination of services and discharge plans. Problem: Lack of coordinated transitional care services and high 30-day readmissions prompted the interdisciplinary team to develop an HF Transition Program (HFTP). Methods: This quality improvement initiative used monthly trend data before and after HFTP implementation. Interventions: The American Heart Association Guidelines for HF Transitions served as a framework for developing the HFTP. Results: Over an 11-month period, 466 patients were enrolled into the HFTP, resulting in 18.2% (n = 82/450) 30-day cumulative readmission rate that is lower than the 21.9% national average. Sixteen patients did not code for HF after discharge. Heart Failure Transition Program calls to patients and families within the first week home were consistently high at 92.3% (430/466). Conclusions: These data show that care coordination and transitional care are important strategies to decrease 30-day HF readmissions.