Implementing a Heart Failure Transition Program to Reduce 30-Day Readmissions

J Healthc Qual. 2021 Mar-Apr;43(2):110-118. doi: 10.1097/JHQ.0000000000000268.


Background: Thirty-day readmissions for heart failure (HF) patients are often considered avoidable and linked to inadequate treatment and poor coordination of services and discharge plans.

Problem: Lack of coordinated transitional care services and high 30-day readmissions prompted the interdisciplinary team to develop an HF Transition Program (HFTP).

Methods: This quality improvement initiative used monthly trend data before and after HFTP implementation.

Interventions: The American Heart Association Guidelines for HF Transitions served as a framework for developing the HFTP.

Results: Over an 11-month period, 466 patients were enrolled into the HFTP, resulting in 18.2% (n = 82/450) 30-day cumulative readmission rate that is lower than the 21.9% national average. Sixteen patients did not code for HF after discharge. Heart Failure Transition Program calls to patients and families within the first week home were consistently high at 92.3% (430/466).

Conclusions: These data show that care coordination and transitional care are important strategies to decrease 30-day HF readmissions.

MeSH terms

  • Heart Failure* / therapy
  • Humans
  • Patient Discharge
  • Patient Readmission
  • Quality Improvement
  • Transitional Care*
  • United States