Lower Proportion of Hospitalizations among Non-Homebound Patients Who Received Home Care after Hospital Discharge for Acute Heart Failure Hospitalization

Introduction Frequent rehospitalizations among patients with heart failure (HF) result in patient burden and cost. Homebound patients with HF qualify for home care after hospital discharge. Whether non-homebound HF patients could also benefit from home care (HC) services through improved transition from hospital to home has not been tested. Hypothesis Home care nursing visits for non-homebound HF patients are likely to improve transition of care from the inpatient to home setting, and result in reduced rehospitalization. Methods We included patients who were discharged between November 2017 and October 2018 from University of Utah hospital, had primary or secondary diagnoses of HF, were ambulatory and ineligible for HC at hospital discharge, and lived within the Salt Lake City area. Patients were either referred for HC services upon hospital discharge or released to home with no intervention. HC services for these patients were provided free of charge. Patients who received the intervention had at least one HC visit by a nurse if they agreed to it while in the hospital. HC nurses followed a modified version of the Discharge Checklist from the American Heart Association's Rise Above Heart Failure materials. We removed questions that would have been addressed in the hospital, maintained those that targeted self-management and medication management and added questions specific to the home environment. This checklist was used by healthcare providers when assisting patients with their transition to home. HC visit nurses provided education as appropriate based on patients’ responses. We used descriptive statistics to compare readmission before or after 30 days by intervention status. Results There were 319 patients that met the eligibility criteria; 60.2% were male, 81.8% were white, and the average age was 62.1. Of the 319 eligible patients, a convenience sample of 70 patients were approached and referral was placed for HC. Of these, 61 patients received HC visits and 9 declined. Based on patient responses to the Checklist, key areas addressed during HC visits were medication management, self-care and adherence to heart failure behaviors. Seven of the 61 patients who received HC (11.5%) were readmitted at ≤30 days after discharge, compared to 55/258 (21.3%) who did not receive HC visits (p = 0.08). Conclusions In this ongoing quality improvement pilot study, we tested utility of HC visits to improve transitions of care after discharge for HF exacerbation in ambulatory patients. We identified specific teaching opportunities related to medication management, self-care and adherence to heart failure behaviors. We show that compared to patients who did not receive HC visits, a lower proportion of patients who received HC visits were readmitted at ≤30 days after discharge. Further testing of this strategy seems warranted.