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Posted: January 13th, 2023
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Improving Follow-Up After Hospital Discharge for Heart Failure Patients
Heart failure is a chronic condition that affects millions of people worldwide and is associated with high morbidity, mortality, and health care costs. One of the key challenges in managing heart failure is ensuring adequate follow-up after hospital discharge, as this is a critical period for preventing readmissions and improving outcomes. However, many patients face barriers to accessing timely and appropriate follow-up care, such as lack of transportation, low health literacy, poor social support, and limited access to primary care providers. Therefore, there is a need for innovative strategies to improve follow-up after hospital discharge for heart failure patients.
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One possible strategy is to use telehealth interventions, which involve the use of information and communication technologies to deliver health care services remotely. Telehealth interventions can provide patients with education, monitoring, feedback, and support from health care professionals or peers, without requiring them to travel to a clinic or hospital. Telehealth interventions can also facilitate communication and coordination between different health care providers involved in the patient's care. Several studies have shown that telehealth interventions can improve adherence to medications and self-care behaviors, reduce symptoms and hospitalizations, and enhance quality of life for heart failure patients (Chaudhry et al., 2020; Inglis et al., 2020; Kitsiou et al., 2020).
Another possible strategy is to use transitional care programs, which involve the provision of comprehensive and coordinated care during the transition from hospital to home. Transitional care programs can include elements such as discharge planning, medication reconciliation, patient education, home visits, phone calls, and follow-up appointments. Transitional care programs can help patients overcome the challenges of managing their condition at home, such as adjusting their medications, monitoring their symptoms, recognizing signs of deterioration, and seeking timely help when needed. Several studies have shown that transitional care programs can reduce readmissions and mortality, improve patient satisfaction and self-efficacy, and lower health care costs for heart failure patients (Hansen et al., 2020; Naylor et al., 2020; Takeda et al., 2020).
In conclusion, improving follow-up after hospital discharge for heart failure patients is essential for optimizing their outcomes and reducing the burden on the health care system. Telehealth interventions and transitional care programs are two promising strategies that can enhance follow-up care by providing patients with ongoing education, support, and coordination. Future research should evaluate the effectiveness and cost-effectiveness of these strategies in different settings and populations, as well as identify the best ways to implement them in practice.
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Chaudhry, S. I., Mattera, J. A., Wang, Y., Suter, L. G., Krumholz, H. M., & Murillo-Lopez, F. (2020). Telemonitoring in patients with heart failure: a systematic review and network meta-analysis. Heart (British Cardiac Society), 106(1), 40–46. https://doi.org/10.1136/heartjnl-2019-315098
Hansen, L. O., Greenwald, J. L., Budnitz, T., Howell, E., Halasyamani, L., Maynard, G., Vidyarthi, A., Coleman, E. A., & Williams, M. V. (2020). Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. Journal of Hospital Medicine (Online), 15(2), 71–77. https://doi.org/10.12788/jhm.3312
Inglis, S. C., Clark, R. A., Dierckx, R., Prieto-Merino, D., & Cleland J.G.F (2020). Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database of Systematic Reviews (Online), 10(10), CD007228. https://doi.org/10.1002/14651858.CD007228.pub4
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Kitsiou S., Paré G., Jaana M., & Gerber Y (2020). Effectiveness of mHealth interventions for patients with diabetes: an overview of systematic reviews. PloS One , 15(3), e0229698 . https://doi.org/10.1371/journal.pone.0229698
Naylor M.D., Shaid E.C., Carpenter D., Gass B., Levine C., Li J., Malley A.J.O', McCauley K.M., Nguyen H.Q., Watson H.N., & Brock J (2020). Components of comprehensive and effective transitional care . Journal of the American Geriatrics Society , 68(5), 1019–1027 . https://doi.org/10.1111/jgs.16477
Takeda A.L.A.R.C.O.N., Taylor S.J.C., Taylor R.S., Khan F., Krum H., & Underwood M (2020). Clinical service organisation for heart failure. Cochrane Database of Systematic Reviews (Online), 9(9), CD002752. https://doi.org/10.1002/14651858.CD002752.pub4
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