Reduction in Re-Hospitalization Rates Utilizing Physical Therapists Within a Post–Acute Transitional Care Program for Home Care Patients With Heart Failure

Abstract

Up to 25% of patients hospitalized with heart failure (HF) are re-admitted within 30 days. The highest risk of re-admission is within the first days after discharge. Transitional care programs usually only involve nurses and physicians. The purpose of this study was to describe a post-acute care program including physical therapists and to evaluate re-admission rates following program implementation. The program provided HF-specific training encouraging nurses and physical therapists to assess HF status and instruct on self-monitoring. Thresholds for communication with medical providers were established. Patient groups before (n = 162) and after implementation (n = 300) were similar. Following implementation, there was a 16% decrease in re-hospitalization with little change in the number of visits. Similar multidisciplinary programs may impact re-hospitalization rates and health care costs for HF.

High-Value Home Health Care for Patients With Heart Failure

“…37 In 1 pre-post study of a program that coordinated nurse and physical therapist home visits for patients discharged with HF, researchers found a 16% absolute reduction in hospital readmissions during the HHC episode of care. 38 …”

Transitional Care Interventions for Patients with Heart Failure: An Integrative Review

“…All studies conducted transitional care interventions for patients with HF. Regarding research design, there were 10 RCTs [16,21,22,24,28,29,32,33,36,38], two quasi-experiments [23,40], two pre-and post-tests [17,26], six cohort studies [18,19,27,34,35,37], and five prospective studies [20,25,30,31,39]. Although it was necessary to establish controls to verify the effects of transitional care interventions, in six of the 25 studies [17][18][19][20]26,39], there was no comparative control group set up to verify the effectiveness of transitional care interventions.…”

“…In 15 of the 25 studies, the primary intervention providers were nurses [16,[20][21][22][23][24][25][26][28][29][30]32,33,37,38], including advanced practical nurses, clinical nurse specialists, research nurses, nurse practitioners, cardiac nurses, registered nurses, nurse case managers, registered nurse case managers, and liaison nurses. A multidisciplinary team served as the primary intervention provider in five studies [17,31,35,36,39]. In the remaining five studies [18,19,27,34,40], the major intervention providers were pharmacists or pharmacy students.…”

“…Subjects presented with various HF types: two studies reported on end-stage HF [28,32], three on chronic HF [16,23,33], two on congestive HF [21,37], one on decompensated HF [29], and the remaining 17 on HF [17][18][19][20]22,[24][25][26][27]30,31,[34][35][36][38][39][40]. To identify HF severity, we considered the New York Heart Association (NYHA) class and left ventricle ejection fraction (LVEF).…”

“…One study reported B-type natriuretic peptide level >200 ng/mL [25], and two studies reported HF with reduced or preserved ejection fraction [17,18]. The remaining 12 studies [20,23,26,27,[30][31][32][33]35,[37][38][39] did not report the participants' severity of HF.…”