(CCSP057) A COMPREHENSIVE TRANSITIONAL CARE PROGRAM FOR HEART FAILURE PATIENTS REDUCES HOSPITAL READMISSION

Background: Heart failure (HF) is a chronic condition with a high burden of mortality and morbidity. The 30-day inpatient readmission rate following a HF hospitalization over the last 10 years remains unchanged at about 20%. The transition from hospital to community care is a critical time in the journey of a patient with HF. A program that supports patients during this period has the potential to reduce the rate of 30-day readmissions. We developed a self-management based transitional care program to support the patient during this vulnerable time called Connecting Care to Home (CC2H). The purpose of this quality assessment study was to evaluate the impact of the CC2H program on hospital readmissions.

METHODS AND RESULTS: This is a retrospective cohort study examining the 30-day readmission and emergency department (ED) visit rates. HF patients from Cardiology and Medicine wards at London Health Sciences Centre (LHSC) with moderate care needs were assessed for CC2H enrolment. Patients were excluded if they were in long-term care, didn’t have a primary care provider or had high baseline care needs. CC2H support included ongoing in-home monitoring with interventional supports as required, a 24/7 phone line, timely clinic follow-up, consistent delivery of HF education and self-care management support in the hospital and home setting. The CC2H and non-CC2H groups were not fully matched for complexity in the analysis.

A total of 454 patients were enrolled in the CC2H program between April 1, 2018 and April 1, 2023. The 30-day readmission rate for non-CC2H enrolled patients was 17.4% as compared to 14.2% for CC2H enrolled patients; a 3.2% reduction. The 30-day ED visit rate for non-CC2H enrolled patients was 25% as compared to 21% for CC2H enrolled patients. The average length of stay (LOS) for non-CC2H was 11.5 days versus 7.6 days for CC2H.

Conclusion: A comprehensive transitional care program reduced 30-day readmission rate and ED visits and reduced LOS. Further analyses would be useful to determine the cost effectiveness of this type of program.