Transition Home Program for Patients with Heart Failure

Hospitalization Rates in Nursing Home Residents with Dementia: A Pilot Study of the Impact of a Special Care Unit. Journal of the American Geriatrics Society. 1990;38(2):108-12
August 7, 2019
Caring Connections
August 7, 2019

Transition Home Program for Patients with Heart Failure

AHRQ. Agency for Healthcare Research and Quality. Transition Home Program for Patients with Heart Failure http://innovations.ahrq.gov/content.aspx?id=2206. Accessed August 13, 2014. Summary The Transition Home for Patients with Heart Failure program at St. Luke’s Hospital in Cedar Rapids, IA, incorporates a number of components to assure patients a safe transition to home or another health care setting. These components include an ongoing enhanced assessment of postdischarge needs, thorough patient and caregiver education, patient-centered communication with subsequent caregivers at handovers, and a standardized process for postacute care followup. The program reduced the 30-day heart-failure-to-heart-failure readmission rate for patients from 14 to 6 percent, and the all-cause heart failure readmission rate is 15 to 17 percent. See the Description section for several updates related to ongoing assessment and patient education; the Results section for updated data on readmission rate and patient satisfaction; and the Planning and Development section for new information about spread to other conditions and an Advance Medical Team pilot (updated February 2013).

Leave a Reply

Your email address will not be published. Required fields are marked *