RESUMEN
BACKGROUND: Despite a variety of national efforts to improve transitions of care for patients at risk for rehospitalization, 30-day rehospitalization rates for patients with heart failure have remained largely unchanged. METHODS: This is a retrospective review of 73 patients enrolled in our hospital-based, physican-directed Heart Failure Transitional Care Program (HFTCP). This study evaluated the 30- and 90- day readmission rates before and after enrollment in the program. The Transitionalist's services focused on bedside consultation prior to hospital discharge, follow-up home visits within 72 hours of discharge, frequent follow-up phone calls, disease-specific education, outpatient intravenous diuretic therapy, and around-the-clock telephone access to the Transitionalist. RESULTS: The pre-enrollment 30-day readmission rates for acute decompensated heart failure (ADHF) and all-cause readmission was 26.0% and 28.8%, respectively, while the post-enrollment rates for ADHF and all-cause readmission were 4.1% (P < 0.001) and 8.2% (P = 0.002), respectively. The pre-enrollment 90-day all-cause and ADHF readmission rates were 69.8%, and 58.9% respectively, while the post-enrollment rates for all-cause and ADHF were 27.3% (P < 0.001) and 16.4% (P < 0.001) respectively. CONCLUSIONS: Our physician-implemented HFTCP reduced rehospitalization risk for patients enrolled in the program. This program may serve as a model to assist other hospital systems to reduce readmission rates of patients with HF.
RESUMEN
BACKGROUND: This study investigated the trend of phone calls in the Banner Good Samaritan Medical Center (BGSMC) Heart Failure Transitional Care Program (HFTCP). The primary goal of the HFTCP is to reduce 30-Day readmissions for heart failure patients by using a multi-pronged approach. METHODS: This study included 104 patients in the HFTCP discharged over a 51-week period who had around-the-clock telephone access to the Transitionalist. Cellular phone records were reviewed. This study evaluated the length and timing of calls. RESULTS: A total of 4398 telephone calls were recorded of which 39% were inbound and 61% were outbound. This averaged to 86 calls per week. During the "Weekday Daytime" period, Eighty-five percent of the totals calls were made. There were 229 calls during the "Weekday Nights" period with 1.5 inbound calls per week. The "Total Weekend" calls were 10.2% of the total calls which equated to a weekly average of 8.8. CONCLUSIONS: Our experience is that direct, physician-patient telephone contact is feasible with a panel of around 100 HF patients for one provider. If the proper financial reimbursements are provided, physicians may be apt to participate in similar transitional care programs. Likewise, third party payers will benefit from the reduction in unnecessary emergency room visits and hospitalizations.