Participation in ACC’s Hospital-to-Home (H2H) “See You in 7” initiative was associated with significantly lower heart failure (HF) readmissions, according to a study published Sept. 9 in JACC: Heart Failure. “See You in 7,” a component of ACC’s H2H initiative, challenges hospitals to ensure all discharged HF and heart attack patients have a follow-up appointment scheduled within seven days of hospital discharge.

In an observational analysis, researchers evaluated the seven-day follow-up and 30-day readmission rates for Medicare HF patients at 10 hospitals participating in the Southeast Michigan “See You in 7” Collaborative and compared them to non-participating hospitals both before joining the program and after one year of participation.

The analysis was divided over the period of one year into pre-implementation, test-intervention and evaluation. During the intervention period, collaborating hospitals chose one or more of the seven care process goals from the “See You in 7” Toolkit, which include identifying HF patients prior to discharge; scheduling and documenting a follow-up visit with cardiology or primary care within seven days of discharge; providing patients with documentation of scheduled follow-up; identifying and addressing barriers to keeping appointments; ensuring patients arrive at scheduled follow-up appointment; and making the discharge summary available to follow-up health care providers.

The results of the study showed that while seven-day follow-up rates increased in both collaborating hospitals and non-participating hospitals, both remained low (31 to 34 percent for collaborating hospitals; 30 to 32 percent for non-participating). However, adjusted 30-day readmission rates significantly decreased in collaborating hospitals compared to non-participating hospitals. Collaborating hospitals saw readmissions decrease 2.6 percent, while non-participating hospitals saw a 0.6 percent reduction.

“Our study clearly shows there are challenges in coordinating early follow-up care, since increases in seven-day post-discharge follow up were modest. However, despite this, hospitals in the program stepped up to address deficiencies in post-hospital care and reduce 30-day readmissions,” said Sandra Marie Oliver-McNeil, DNP, ACNP-BC, a study author and assistant professor of nursing at Wayne State University. “Through collaboratively addressing the ‘See You in 7’ goals, hospitals participating in this program learned from each other when helping their patients transition from hospital to home, and they should serve as an encouraging example for other regional hospitals to share best practices.”

According to Harlan M. Krumholz, MD, SM, FACC, “the application, rigorous testing and open sharing of good ideas is at the heart of H2H program.” He adds that “this project shows the value of engaging patients and caregivers in the process leading up to hospital discharge and achieving the goal of the H2H initiative to improve the transition from hospital to home.”

“These [data] are consistent with other national data and are an important reflection of the current state of health care in the U.S.,” state Adrian F. Hernandez, MD, MHS, and Adam D. DeVore, MD, in an accompanying editorial comment. “Not all health care systems have fully integrated outpatient care networks making transitional care challenging.”

Further commenting on the study, JACC: Heart Failure Editor-in-Chief Christopher O’Connor, MD, FACC, explains that, “Readmissions of HF patients remain one of the most important clinical challenges today. Transitional care programs may represent our best opportunity to reduce the burden on patients and health systems.”

Keywords: Ambulatory Care, Cost of Illness, Heart Failure, Medicare, Myocardial Infarction, Patient Discharge, Patient Readmission, Primary Health Care

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