Comprehensive Heart Failure Transition Program

This hospital system has consistently had readmission rates greater than the Centers for Medicare & Medicaid Services (CMS) national benchmark of 21.9%, which is both detrimental to our patients and the hospital to incur readmission penalties yearly. Before this program began there was no process to transition care from inpatient to outpatient for the HF population; key members that touched HF patients operated in silos. Based on consistently high readmission rates and the need for improved outcomes, a comprehensive HF discharge program was designed and implemented house-wide. Transitional care coordination includes providing education, scheduling post-discharge follow-up appointments, and providing HF toolkits. There was a retrospective analysis of data three months after the implementation of QI initiatives.