The Importance of the “Hospital-to-home” Connection in Treating Patients with Heart Failure.

Heart failure is a common and serious illness. Thirty day mortality rate after a hospitalization for heart failure is around 10%, and one year mortality rate is 20%.  Up to 70% of these deaths are due to cardiovascular causes.

In addition, early readmission rate after a heart failure hospital discharge is very high—20% of these patients are re-hospitalized within 30 days, with a mean time to readmission of 12 days post-discharge.  Heart failure is the diagnosis associated with the highest readmission rate, and these readmissions are estimated to cost the Medicare program up to 26 billion dollars yearly.

What can we do in our daily care of these patients to alter these dire outcomes?  At Cooper, we emphasize 4 major practices.  First, patients and their families must receive education regarding principles of self- management of heart failure, including low sodium diet, appropriate oral fluid restriction, daily weight measurement, knowledge about their medication program and the importance of regular physical activity.

Second, it is critical to identify, at the time of hospital discharge, the medical professional or team that will be responsible for their heart failure care. An easy and convenient way for the patient and family to communicate with that team should be identified.  An early follow up appointment should be scheduled with their medical caregiver, within one week after discharge.  Details of the hospitalization and discharge medications should be communicated to the team.  Communication between the hospital team and a different outpatient care team is vitally important and cannot be ignored.

Third, a phone call to the patient should be performed by hospital staff within 24-72 hours post-discharge, to review symptoms and medication adherence. Fourth, early in-home follow up visits to reassess heart failure status, medications and review heart failure teaching is vital.

All of these steps have been shown to help to improve the prognosis and reduce the high readmission rate for our heart failure population.

Fredric L Ginsberg, MD, FACC, FCCP

Co-Medical Director, Cooper Heart Institute

Director of Operations, Cooper Heart Institute

Director of Nuclear Cardiology

Clinical Cardiologist

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