A comprehensive transitional care program for heart failure is associated with reduced 30-, 60-, and 90-day hospital readmissions and emergency department visits
Mohammed J. Albaghdadi, Karen Geukers, Kiera Belletti, Elizabeth Farrell, Ryan Davey, Sabe De, Stuart Smith, Robert McKelvieAbstract
Background:
Heart failure (HF) is a leading cause of morbidity and mortality, and short-interval hospital readmissions and emergency department (ED) visits often stem from inadequate post-discharge follow-up. Connecting Care to Home (CC2H), a transitional care program supporting patients with HF during the first 4 weeks after discharge, was launched. The primary outcome was a 30-day composite of hospital readmissions or ED visits; secondary outcomes were these events at 60 and 90 days.
Methods:
In this retrospective study (August 2018–January 2024), patients with HF enrolled in a 28-day transitional care program were provided with individualized care plans, education, in-person assessments, remote monitoring, a 24/7 line, and coordinated follow-up. They were compared with matched controls receiving standard discharge planning. Matching was based on the Health-Based Allocation Model Inpatient Group score.
Results:
Among 511 matched pairs, program enrolment was associated with 38% lower odds of the composite 30-day outcome (odds ratio [OR], 0.62; 95% CI, 0.47–0.83,
Conclusion:
A structured transitional care program combining multidisciplinary support, patient education, and timely follow-up was associated with substantial reductions in short-term hospital readmissions and ED visits among patients with HF, with benefits persisting to 90 days. These real-world data support broader implementation within integrated health care systems to reduce acute care utilization and improve patient-centred outcomes.