Implementing a Transitional Care Program for High-Risk Heart Failure Patients: Findings from a Community-Based Partnership Between a Certified Home Healthcare Agency and Regional Hospital

Abstract

Provisions within the recently passed health reform law provide support for new approaches to reducing the high cost of care for clinically complex patients. This article describes the characteristics of a recent transitional care pilot initiative that aims to reduce hospital readmissions among high-risk heart failure patients. The program was designed and implemented through a joint collaboration between a Certified Home Healthcare Agency and regional hospital. As a preliminary assessment of the impact of this program on patient outcomes, we compare the odds of rehospitalization among patients who received the transitional care services (n = 223) and a similar group of patients who received usual home care services (n = 224). Analyses indicated that patients who received the transitional care services were significantly less likely to be readmitted to the hospital than the patients in the control group. Although preliminary, our findings suggest that providing transitional care services to high-risk heart failure patients can be an effective deterrent against patterns of rehospitalization. The opportunities and challenges associated with implementing this pilot program are discussed.

Transitions of Care in Heart Failure

“…Overall, the effect of interventions on rehospitalization declined over time, except in 1 report in which there was greater benefit in rehospitalization between groups in the later time period. 23 In 6 reports of non-RCT or quasi-experimental design, rehospitalization was red uced, 19,32,53,54,56,57 and in 2 RCTs, no reduction in rehospitalization was observed between groups. 20,21 Although mortality was not commonly reported, rehospitalization and mortality may be competing outcomes.…”

“…In 6 quasiexperimental designs, postintervention and preintervention rehospitalization rates were compared, or intervention groups were compared with concurrent control subjects, and sample sizes ranged from 126 to 1393 participants. 19,32,53,54,56,57 Only 5 trials enrolled patients with HF exclusively. 21,27,53,56,57 Duration of interventions varied from a few days within discharge to 3 months after discharge.…”

“…19,32,53,54,56,57 Only 5 trials enrolled patients with HF exclusively. 21,27,53,56,57 Duration of interventions varied from a few days within discharge to 3 months after discharge. Overall, the effect of interventions on rehospitalization declined over time, except in 1 report in which there was greater benefit in rehospitalization between groups in the later time period.…”

“…Of 13 studies reviewed in Table 3, 7 studies were RCTs with sample sizes of 192 to 750 participants, 18,20,21,23,27,45,55 rehospitalization was a primary end point in 10 reports, [18][19][20]23,32,45,53,54,56,57 and rehospitalization was measured at multiple time points, from 30 days to 1 year after the index discharge. In 6 quasiexperimental designs, postintervention and preintervention rehospitalization rates were compared, or intervention groups were compared with concurrent control subjects, and sample sizes ranged from 126 to 1393 participants.…”

Facilitating safe patient transition of care: A qualitative systematic review

“…During the 6-month follow-up period, patients in the HBI group had fewer unplanned readmissions (p = .03). A third study [26] , a retrospective, observational study, evaluated the likelihood of hospital readmission for heart failure patients who had received transitional care services. Using a logistic regression equation, the odds ratio of 30-day readmission among intervention patients was 0.57 (p < .01).…”