The following are 10 key points to remember from this American Heart Association (AHA) Statement on transitions of care in heart failure (HF):

1. Transitions of care in HF refer to individual interventions and programs with multiple activities that are designed to improve shifts or transitions from one setting to the next, usually hospital to home.
2. After patient characteristics were controlled for in multivariate regression analysis, three hospital-based factors remained important predictors of 30-day hospital readmissions: evaluation of left ventricular function, smoking cessation, and HF admissions per year.
3. There are eight common components to disease management programs after hospital discharge for HF: telephone follow-up, education, self-management, weight monitoring, sodium restriction or dietary advice, exercise recommendations, medication review, and social and psychological support.
4. Post-discharge care was separated into clinic care (physician office with nurses primarily managing HF medications), multidisciplinary care (multiple services by multiple care providers), and case management models (transition care programs aimed at early, intense post-discharge monitoring).
5. Compared with usual care, clinic care models failed to reduce rehospitalization and mortality, but case management improved late mortality (≥6 months after discharge). Case management and multidisciplinary care programs improved early (within 6 months) and later HF rehospitalization and all-cause rehospitalization.
6. The role of the person directing interventions most commonly was a nurse. Patient education involved teaching principles about HF such as diet, signs and symptoms of HF, self-care expectations, and medication counseling and education.
7. Most programs had a first telephone call follow-up post-discharge within 48 to 72 hours and most follow-up appointments were within 7-10 days post-discharge. In one report reviewed, 46% of patients had problems in understanding and complying with diet and self-care needs.
8. Efficient handoff communications to outpatient healthcare providers must be improved for more effective medication reconciliation and follow-up care.
9. Optimal transitions can decrease rates of rehospitalization, risk for adverse clinical events, and promote patient satisfaction.
10. HF programs should consider implementing principles of transition of care in high-risk patients with chronic HF.

Keywords: Heart Failure, Ventricular Function, Left, Hospitalization, Self Care, Case Management, Counseling, Diet, Disease Management, Follow-Up Studies, Health Personnel, Medication Reconciliation, Outpatients, Patient Satisfaction, Smoking Cessation

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