Nine interventions for transitions of care in heart failure may assist in achieving optimal clinical and patient-centered outcomes, according to a scientific statement that addressed patient, hospital, and clinician barriers.
The scientific statement focused on the transition component of care models and appeared online Jan. 20 in Circulation: Heart Failure.
The 9 interventions are as follows.
Systematically implement principles of transition of care programs in high-risk patients with chronic heart failure, such as medication reconciliation, very early postdischarge contact and communication between hospital clinicians and patients or outpatient clinicians, an office follow-up within a week of discharge, patient education about self-care, and sharing of patient's health records with the patient and postdischarge providers.
Routinely assess patients for high-risk characteristics that may be associated with poor postdischarge clinical outcomes, such as cognitive difficulties, impaired learning capabilities, language barriers, and long travel time to clinicians.
Ensure that qualified and trained heart failure nurses or other clinicians treat patients, by assessing clinician knowledge and comfort on patient education and interdisciplinary care coordination services.
Allot adequate time in the hospital and postacute setting to deliver complex interventions, including assessing patients' or caregivers' capabilities to independently understand and complete self-management interventions.
Implement handoff procedures at hospital or post-acute care discharge, and provide a record in a timely manner that includes key details such as medications used, discharge medications, procedures, treatments, postdischarge care expectations, planned rehospitalization and/or follow-up services, known psychosocial issues, and medication reconciliation.
Develop, monitor, and ensure transparency of quality measures, using a structure, process, and outcome framework.
Consider patients' perceptions of quality of life as a surrogate for physical, psychological, and social concerns that require support during the transition.
Ensure transition of care component details are in writing, such as a training manual, to promote adherence and consistent application by clinicians.
Use health informatics technology that is patient- and clinician-centric to assist with program sustainability.
“Patient experiences during transitions of care can be stressful, particularly when post-hospitalization care is poorly executed as a result of inadequate coordination of resources or follow-up,” the scientific statement said. “Health care leaders must facilitate and ensure follow-through of transition interventions, continuity of services, and continuous quality improvement monitoring to ensure high-quality intervention implementation and minimization of gaps and disparities.”