HF Learning Pathway Explores Ways to Improve Care Transitions

Approximately 5.1 million people in the U.S. alone have heart failure (HF), costing an estimated $32 billion annually, according to the Centers for Disease Control and Prevention. In addition, countries around the world also struggle with high mortality rates and costs.

Over the years, the ACC has developed guidelines, performance measures, clinical toolkits, educational programs and products, and quality programs aimed at reducing the incidence of HF. The College’s Hospital to Home (H2H) initiative has been one of the most successful programs, with a long track record of helping hospitals reduce readmissions and improve transitions of care by sharing best practices and disseminating evidence-based strategies and toolkits.

Recently, a study published in the Journal of Nursing Care Quality showed that regional collaboration between health care systems using the H2H Early Follow-up See You in 7 Toolkit is associated with reduced 30-day readmission.

The study, led by Joy Pollard, PhD, ACNP-BC, looked at 10 hospitals enrolled in the Southeast Michigan See You in 7 Hospital Collaborative. Based on aggregate claims data for Medicare fee-for-service beneficiaries for HF admissions between May 1, 2011 and April 30, 2012 and May 1, 2012 to March 30, 2013, the study showed that “the overall 30-day readmission rate was reduced more in the collaborating hospitals that in the noncollaborating hospitals (from 29.32 percent to 27.66 percent vs. from 27.66 percent to 26.03 percent).”

"The Collaborative members feel this regional project was a success on many levels,” said Pollard. “By working together as a team on a common goal, both patients and hospitals gained benefit. Using the See You in 7 Toolkit provided a starting place to hone best practices, see what worked and track progress toward reducing heart failure readmissions.”

Pollard will join incoming ACC Vice President Mary N. Walsh, MD, FACC, and others, in talking about the impacts of regional collaboration, as well as homecare, tele health, post-hospital follow-up and hemodynamic monitoring, as part of a special session today focused on “Navigating Heart Failure Care Transitions and Preventing Readmissions.”  The session will also offer a closer look at the ACC’s Patient Navigator Program – an innovative pilot with 35 hospitals that are pioneering a team approach to keep patient’s health and at home following a heart attack. AstraZeneca is the founding sponsor of the program, now in its second year.

“The Patient Navigator Program is a unique collaboration between the cardiovascular care team, patients and families,” said ACC President Patrick T. O’Gara, MD, FACC. “The program also coincides with national initiatives to reduce readmission rates for patients with cardiovascular conditions.”

Search the ACC.15 App for additional HF Learning Pathway sessions.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: ACC Annual Scientific Session, Centers for Disease Control and Prevention (U.S.), Fee-for-Service Plans, Follow-Up Studies, Heart Failure, Hemodynamics, Home Care Services, Hospitals, Medicare, Patient Navigation, Patient Readmission

< Back to Listings