Evaluation of a Transitional Care Program After Hospitalization for Heart Failure in an Integrated Health Care System.

Prompted by null findings from several care transition trials and practice changes for heart failure in recent years, leaders from a large integrated health care system aimed to reassess the outcomes of its 10-year multicomponent transitional care program for heart failure (HF-TCP). To examine the association of the individual HF-TCP components and their bundle with the primary outcome of all-cause 30-day inpatient or observation stay readmissions. This retrospective cohort study included patients enrolled in the HF-TCP during an inpatient encounter for heart failure at 13 Kaiser Permanente Southern California hospitals from January 1, 2013, to October 31, 2018, who were followed up from discharge until 30 days, readmission, or death. Data were analyzed from May 7, 2019, to May 1, 2020, with additional review from September 2 to October 1, 2020. Patients received 1 home health visit or telecare (telephone) visit from a registered nurse within 2 days of hospital discharge, a heart failure care manager call within 7 days, and a clinic visit with a physician or a nurse practitioner within 7 days. Multivariable proportional hazards regression models were used to estimate the probability of 30-day readmission for those who received the individual or bundled HF-TCP components compared with those who did not. A total of 26 128 patients were included; 57.0% were male, and the mean (SD) age was 73 (13) years. The 30-day readmission rate was 18.1%. Both exposure to a home health visit within 2 days of discharge (hazard ratio [HR], 1.03; 95% CI, 0.96-1.10) and a 7-day heart failure case manager call (HR, 1.08; 95% CI, 0.99-1.18) compared with no visit or call were not associated with a lower rate of readmission. Completion of a 7-day clinic visit was associated with a lower readmission rate (HR, 0.88; 95% CI, 0.81-0.94) compared with no clinic visit. There were no synergistic effects of all 3 components compared with clinic visit alone (HR, 1.05; 95% CI, 0.87-1.28). This study found that HF-TCP as a whole was not associated with a reduction in 30-day readmission rates, although a follow-up clinic visit within 7 days of discharge may be helpful. These findings highlight the importance of continuous quality improvement and refinement of existing clinical programs.