Session presented on: Monday, July 22, 2013:

Purpose: To evaluate if the use of transitional care services through home care services reduced hospital readmissions as compared to self-care at home for heart failure patients. In addition, the four key processes of the Institute of Healthcare Improvement (IHI) Transforming Care at the Bedside How to Guide for Patients with Heart Failure were evaluated.

Methods: Retrospective chart reviews were performed of hospital and home care records of Medicare patients discharged (N=76) from a large northern NJ medical center January 2010-April 2010 with a diagnosis of heart failure. Through interviews/observations of work processes, the IHI four processes from admission assessment to post-acute follow up were evaluated. SPSS version 17 was utilized using t-tests, chi-square, and binary logistic regression.

Results: There was no statistical significant difference in hospital readmissions within 30-days between patients discharged home to self-care or home care services p= 0.181. There was no significant difference in patients who received complete discharge instructions for those not readmitted and those readmitted, p= 0.084. There was a statistically significant difference in readmissions for patients who had had a longer length of stay (LOS) on their index admission for readmitted patients having a mean LOS of 5.5 days (SD=2.6) compared to non-readmitted patients mean LOS of 3.5 days (SD=2.2), at p= 0.002. Hospital discharge instructions did not specify sodium restrictions, but home care diets did. In the hospital, teach back was not routinely utilized. Weight loss was not trended to model the importance of daily weights through diuresis therapy and symptom management.

Conclusions: Opportunities for improving teaching and learning processes for all heart failure patients and families were identified based on evidence-based practices. Improvements in reducing readmissions can be measured against this data once telehealth is fully implemented in home care. The data provided a stimulus for organizational change to improve patient care processes, improve care transitions, and'reduce readmissions prior to the impact of reduced medical payments for high readmission rates.