Heart failure, the leading cause of hospitalization among adults over 65 in the US, is responsible for billions of dollars in healthcare costs each year. Despite advances in cardiac care, readmissions related to heart failure remain a persistent problem nationwide, with 1 in 4 patients reported to be readmitted within 30 days of discharge. 

Taking proactive steps to prevent readmission is essential to providing quality care for patients with cardiovascular conditions. Not only does reducing readmission rates minimize costs, but it also helps improve patient outcomes and satisfaction by ensuring that proper protocols are in place before discharge. 

As value-based healthcare models continue to gain momentum, physicians must be aware of innovative strategies they can utilize to reduce readmission rates while delivering patient-centered care. 

Health System Strategies to Reduce Readmissions   

Studies show that no single strategy is responsible for reducing readmissions. Heart failure readmission prevention must be more holistic and involve a combination of patient education, a clear discharge strategy and transitional care, medication reconciliation, and scheduled follow-ups.  

This blog post zooms into four key strategies value-based care providers can employ to prevent heart failure readmissions. 

Patient Education 

The revolving door effect of patients discharging from and re-entering the health system is primarily attributed to the lack of patient education. Educating patients does not stop at providing them with written discharge instructions and disease-related handouts. This doesn’t guarantee engagement or comprehension.  

Clinicians can instead use teach-back techniques to evaluate the patient’s level of understanding—telehealth and remote patient monitoring (RPM) tools make implementing effective patient education effortless. Patients can easily retrieve the information they need, watch informational videos on their own time, and attempt teach-back quizzes to test their knowledge.  

Discharge Planning 

The American College of Cardiology recommends that heart failure patients with a high risk of readmission be scheduled with post-discharge appointments within seven days of discharge. The “See You in 7” initiative reduced the 30-day readmission rate by 2.6 percent. 

Early and structured follow-up after hospitalization is critical to reducing readmissions. However, patients and the health system may find it challenging to comply with such early post-admission clinic visits for various reasons, including time and resource constraints. Therefore, a study was conducted to evaluate the efficiency of conducting a telephone visit in place of in-person visits.

The result: there was no significant difference in terms of health outcomes, but both clinicians and patients found telephone appointments more convenient. 

Telehealth and RPM take the convenience of remote monitoring one step further by offering structured post-discharge appointment planning with scheduling and reminders features. 

Transitional Care 

Transitioning effectively between inpatient and outpatient settings for heart failure patients involves a lot of care, coordination, and collaboration. Higher-quality discharge summaries and timely transitions are linked to lower readmissions in heart failure patients. Issues like patients being unaware of the changes in their medications can be mitigated when post-discharge communication is clear.  

Essentially, successful transitional care involves teamwork between multi-professionals, timely and clear information, medication reconciliation and adherence, support group engagement, monitoring of post-discharge symptoms, and outpatient follow-ups. 

Telehealth and RPM are powerful tools that can effortlessly transition patients into their home settings. These tools effectively reduce readmissions, from easing patient-practitioner communication to providing disease and medication-related information.  

Nurse:Patient Ratios 

A study revealed that the average 30-day readmission rate for heart failure patients increases by 7% for each patient added to a nurse's workload. Hospitals with higher nurse staffing ratios also have 41% lower odds of being penalized by Medicare for excessive readmissions. These are clear indications that having a balanced nursing workload is vital for optimal patient support and outcomes, thus reducing readmissions.  

Telehealth and RPM programs can help manage nurses’ workload by: 

  • Empowering patients to monitor and manage their disease 
  • Monitoring vital signs and ensuring medication adherence remotely 
  • Determining the patient’s health status and intervening as needed 
  • Reducing in-person visits, the occurrence of emergency room diversions, and unnecessary hospitalizations 

HRS is Here to Help with Scalable RPM Solutions

With HRS’ cardiac monitoring solutions, healthcare providers can effectively support heart failure patients and decrease readmissions through symptom surveys, patient education, and vital signs monitoring. In addition to regular in-person visits, providers can quickly triage through virtual visits when there is a sudden exacerbation of symptoms. 

Explore HRS' Cardiac RPM Solutions