Congestive heart failure is a leading cause of hospitalization in adults greater than 65 years old. It is estimated that over 1 million people are hospitalized annually with a primary diagnosis of heart failure. Given the challenges of heart failure management, readmission within 30 days of hospital discharge is estimated to be 24%. Contributing factors include medication adherence, lack of timely follow-up, psychosocial and socioeconomic factors. 

  The two major factors related to hospital readmission are lack of follow-up within 7 days of discharge and not having medications in hand upon discharge. Given these factors, a comprehensive care plan with a transition of care team is essential.

  Approximately 20% of Medicare beneficiaries are readmitted within 30 days of discharge, estimating to cost the American public over $15 billion per year. While some readmissions are unavoidable, comprehensive discharge planning has shown to reduce rates by 25%.

  Given the enormous cost of readmissions, the Medicare Affordable Care Act was enacted to offer incentives for overall value of care. Those institutions that do not meet quality metric standards may be penalized up to 3% of total Medicare reimbursement. 


To evaluate the benefit of a transition of care team to improve hospital quality of care metrics in patients admitted for decompensated congestive heart failure.


  The transition of care congestive heart failure (CHF) team is comprised of cardiac nurses and healthcare navigators that are trained on treatment and transition of care for CHF. Patients admitted with a primary diagnosis of decompensated CHF were treated with standard of care in addition to being overseen by the CHF team. This was compared to those patients admitted to other units without an assigned CHF team.

  Patients were educated on their diagnosis of CHF through direct teaching by nurse navigators and utilizing a teach-back approach throughout the initial hospitalization. They were then followed by the nurse navigators through 30 days. Patients assigned to a CHF team were given appointments within 7 days of discharge and offered medications to be filled prior to discharge. Outcomes in quality metrics including 30-day hospital readmission were compared to current standard of care.


  A transition of care CHF team improves medical education, patient access to medication and post discharge medical follow-up within 7 days. This correlates with improved all-cause 30-day readmission compared with national standards of care as well as current hospital standards. The cumulative 30-day readmission rate over the 12-month course of this project was 12.3% for those benefiting from the CHF team. All other patients not being overseen by a transition of care team had a rate of 17.1%. The combined readmission rate was 14.2%, which is markedly reduced compared to prior in-hospital rates and the national average of 20.4% and 24%, respectively. These outcomes from a transition of care team can be a model to provide enhanced care across the medical spectrum.