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

2016 ◽  
Vol 29 (1) ◽  
pp. 7-12 ◽  
Author(s):  
Amy Miller ◽  
Erin E. Edenfield ◽  
Janet Roberto ◽  
Joann K. Erb
Keyword(s):  
Heart Failure ◽  
Program Implementation ◽  
Transitional Care ◽  
Physical Therapists ◽  
Care Program ◽  
Self Monitoring ◽  
Admission Rates ◽  
Hospitalization Rates ◽  
Patients With Heart Failure ◽  
Patient Groups

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.

7 An APN-Led Transitional Care Program to Reduce 30-Day Readmissions in Patients with Heart Failure

Heart & Lung ◽  
2017 ◽  
Vol 46 (3) ◽  
pp. 214
Author(s):  
Miaozhen Li ◽  
Diane Whitehead ◽  
Cindy Peters ◽  
Pat Long
Keyword(s):  
Heart Failure ◽  
Transitional Care ◽  
Care Program ◽  
Patients With Heart Failure

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

2020 ◽  
Vol 17 (8) ◽  
pp. 2925 ◽  
Author(s):  
Hai Mai Ba ◽  
Youn-Jung Son ◽  
Kyounghoon Lee ◽  
Bo-Hwan Kim
Keyword(s):  
Heart Failure ◽  
Hospital Readmission ◽  
Transitional Care ◽  
Hospital Readmissions ◽  
Recovery Period ◽  
Functional Decline ◽  
Integrative Review ◽  
Patients With Heart Failure ◽  
Ed Visits ◽  
The Common

Heart failure (HF) is a life-limiting illness and presents as a gradual functional decline with intermittent episodes of acute deterioration and some recovery. In addition, HF often occurs in conjunction with other chronic diseases, resulting in complex comorbidities. Hospital readmissions for HF, including emergency department (ED) visits, are considered preventable. Majority of the patients with HF are often discharged early in the recovery period with inadequate self-care instructions. To address these issues, transitional care interventions have been implemented with the common objective of reducing the rate of hospital readmission, including ED visits. However, there is a lack of evidence regarding the benefits and adverse effects of transitional care interventions on clinical outcomes and patient-related outcomes of patients with HF. This integrative review aims to identify the components of transitional care interventions and the effectiveness of these interventions in improving health outcomes of patients with HF. Five databases were searched from January 2000 to December 2019, and 25 articles were included.

scholarly journals Outcomes in patients with heart failure treated in hospitals with varying admission rates: population-based cohort study

2014 ◽  
Vol 23 (12) ◽  
pp. 981-988 ◽  
Author(s):  
R Sacha Bhatia ◽  
Peter C Austin ◽  
Therese A Stukel ◽  
Michael J Schull ◽  
Alice Chong ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cohort Study ◽  
Population Based ◽  
Admission Rates ◽  
Patients With Heart Failure

Applying the Transitional Care Model to Elderly Patients with Heart Failure

2000 ◽  
Vol 14 (3) ◽  
pp. 53-63 ◽  
Author(s):  
M. Brian Bixby ◽  
Joanne Konick-McMahon ◽  
Catherine G. McKenna
Keyword(s):  
Heart Failure ◽  
Elderly Patients ◽  
Transitional Care ◽  
Care Model ◽  
Patients With Heart Failure

scholarly journals Evaluation of a Transitional Care Program After Hospitalization for Heart Failure in an Integrated Health Care System

2020 ◽  
Vol 3 (12) ◽  
pp. e2027410
Author(s):  
Aileen Baecker ◽  
Merry Meyers ◽  
Sandra Koyama ◽  
Maria Taitano ◽  
Heather Watson ◽  
...  
Keyword(s):  
Heart Failure ◽  
Health Care ◽  
Health Care System ◽  
Transitional Care ◽  
Care Program ◽  
Integrated Health Care ◽  
Integrated Health ◽  
Integrated Health Care System ◽  
Care System

Diabetes und Herzinsuffizienz

2019 ◽  
Vol 14 (03) ◽  
pp. 180-192
Author(s):  
Philipp H. Baldia ◽  
Nikolaus Marx ◽  
Katharina A. Schütt
Keyword(s):  
Diabetes Mellitus ◽  
Heart Failure ◽  
Early Stage ◽  
Hospitalization Rates ◽  
Patients With Heart Failure ◽  
Patients With Diabetes ◽  
Treatment Of Diabetes ◽  
The Common ◽  
Current Guidelines ◽  
Positive Effect

AbstractDiabetes mellitus is a very important comorbidity in patients with heart failure, as the common presence of both diseases significantly worsens the prognosis of patients. In order to improve the outcome of these patients, it is essential to diagnose both diseases at an early stage and to treat them in accordance with guidelines. In particular, a differentiated medication plays a crucial role. The therapy of heart failure does not differ in patients with diabetes and patients without diabetes. In the treatment of diabetes mellitus, however, it is very important to choose substances that have a positive effect on the cardiovascular outcome of patients. First-line treatment of diabetes in patients with cardiovascular diseases should be metformin, followed by a SGLT-2 inhibitor or GLP-1 receptor agonist with proven cardiac benefit. A rigorous adjustment of risk factors according to current guidelines reduces cardiovascular mortality and hospitalization rates. Glitazones and saxagliptin are associated with increased hospitalization rates and should be avoided in heart failure.

The Impact of Telephonic Follow-Up Within 2 Business Days Postdischarge on 30-Day Readmissions for Patients With Heart Failure

2021 ◽  
pp. JDNP-D-19-00079
Author(s):  
Victoria M. Chestnut ◽  
Karen Vadyak ◽  
Matthew M. McCambridge ◽  
Michael J. Weiss
Keyword(s):  
Heart Failure ◽  
Chart Review ◽  
Transitional Care ◽  
Hospital Readmissions ◽  
Hospital Discharges ◽  
Phone Calls ◽  
Adult Participants ◽  
Patients With Heart Failure ◽  
The Impact

BackgroundHeart failure (HF) is a chronic condition associated with high rates of hospital readmissions. The prevalence and costs of HF are expected to rise dramatically by 2030 (Heidenreich,et al., 2013).ObjectiveA 24-month, retrospective study was conducted using electronic medical record (EMR) chart review, seeking to identify if postdischarge follow-up phone calls decreased 30-day readmissions in individuals with HF.MethodsThe study included 705 adult participants who were admitted to the hospital for HF. Some received a postdischarge call within 2 business days of discharge, and some did not.ResultsParticipants who received the postdischarge call were less likely to be readmitted (20.1%) than participants who did not receive a postdischarge call (28.8%; p = .007). Participants who received the postdischarge call were more likely to have a follow-up visit within 14 days (70.1%) than participants who did not receive a postdischarge call (30.2%; p < .001).ConclusionsThe findings from this study may help to drive future transitional care strategies for individuals diagnosed with HF.Implications for NursingNurse-led transitional care interventions offer potential solutions to ensure safe, effective hospital discharges.

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