A Multidisciplinary Team’s Management of Heart Failure with the Readmission Engagement and Care Transitions Program

Authors: Brian Stein, MD; Anupama Rao, MD; Kathleen Egan, LCSW, ACM; and Erica Feddeler, RN, NP

Heart failure (HF) hospitalization and readmission is a concern for many hospitals in the U.S. HF has accounted for approximately 6% of all general medicine hospitalizations at Rush University Medical Center since January 2020. Nationally, up to 25% of HF patients hospitalized are readmitted within 30 days, and Rush’s average in 2020 was 23.46%. In 2019 and 2020, HF readmission rates at Rush were sporadic and consistently over the national average. This was reflected in Rush’s effectiveness ranking from the 2020 and 2021 Quality and Accountability rankings. Cardiology had the highest service line readmission rate for Rush. Within the Department of Cardiology, the HF diagnosis-related groups (DRG) had the highest readmission rate and highest volume of cases. This, combined with a literature review on effective patient care, led Rush to implement a transitional care program for patients following their HF hospitalization to reduce health care costs and improve their mortality. HF patients became the focus of the Readmission Engagement and Care Transitions (REACT) program. This multidisciplinary team assists with heart failure management during hospital stays until discharge and schedules appointments for REACT and primary care clinics before the patients are discharged. Patients are closely monitored for 30 days after hospital discharge, starting with the REACT case management nurse completing a care transition call within the first 24 to 48 hours of discharge. This allows the case management nurse to identify new symptoms, perform medication reconciliation and provide HF education. Within seven days of discharge, patients are seen in the REACT outpatient clinic and within 14 days of discharge, they are seen by their primary care physician to continue the management of symptoms and medication. Throughout the 30 days, the REACT case management nurse contacts the patients weekly, partners with home health and works with the REACT case management social worker to assist patients with barriers to remaining in the community setting.

Since implementing the REACT program, heart failure readmissions have consistently and steadily decreased. The average Rush readmission rate in 2021 was 19.16% compared to the 2020 average of 23.46%. Focusing on HF readmissions has also improved the overall cardiology readmission rates as defined by the quality and accounting rankings. In 2020, the average cardiology readmission rate for Rush was 17.93%, which in 2021 improved to 14.67%. In addition, the program assisted in the identification of hospitalized heart failure patients, which led to an improvement in medical management and patient education. With the dedicated focus of the REACT team, readmission rates decreased while the ability to equip patients to better care for themselves increased. The improvement has also been recognized through the American Heart Association Target HF initiatives with Rush receiving the Get with the Guidelines Heart Failure Silver Plus, Target: HF Honor Roll.