Date of Publication



Reducing 30-day Heart Failure Readmissions Utilizing Transitional Care

Melissa Beaudry, MSN, APRN, FNP-BC

Purpose: Heart failure has a high prevalence and is associated with increased healthcare spending. The cost is driven by the frequency of hospitalizations and high rates of 30-day readmissions. The American Heart Association identified transitional care management (TCM) as effective in reducing hospitalizations. The purpose of this quality improvement (QI) project was to increase outreach to patients being discharged from the hospital with HF over 6 weeks in a rural primary care practice. A secondary aim was to evaluate how this impacted 30-day readmissions and ER utilization.

Methods: A retrospective chart review was conducted 12 weeks before implementation to obtain baseline TCM data. A one-hour educational training session was provided to nurses on TCM activities. These included post-discharge phone calls made within 48-72 hours and office visits 5-7 days after discharge. A retrospective chart review was performed during the intervention period and for 12 weeks post-intervention.

Results: The number of post-discharge phone calls increased by 26% and office visits decreased by 3% during the intervention period. The number of 30-day readmissions and ER visits were reduced by 29% and 14% respectively. No patients received TCM activities in the post-intervention period. Results were limited by the low number of participants.

Conclusion: TCM represents a feasible way to prevent 30-day readmissions and ER utilization, thereby reducing healthcare spending. TCM requires office resources to be successful, notably adequate nursing staff with clear roles/responsibilities and appointment availability. Measuring patient quality of life or understanding of disease self-management is an area of future study.

Keywords: heart failure, transitions of care, care transitions, patient readmission, readmission

Document Type


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