Implementation of early follow-up care after heart failure hospitalization.

OBJECTIVES The evidence supporting early postdischarge hospital follow-up is limited. We implemented a new, multidisciplinary, multistrategy heart failure (HF) team approach that included new clinic slots, predischarge nurse visit, providing a blood pressure cuff and scale, and cardiologist supervision. STUDY DESIGN Pre- vs postintervention evaluation of outcomes in patients hospitalized with HF between September 1, 2010, and May 30, 2013. We utilized the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework to evaluate the intervention. METHODS For the quantitative evaluation, we compared the proportion of patients in both groups who were scheduled for and completed a cardiology appointment within 7 days after hospitalization ("reach"). We created a Cox model to evaluate the "effectiveness" of the intervention period on a 30-day composite outcome (all-cause emergency department [ED] visit, all-cause hospitalization, or death). In qualitative evaluation, we describe the adoption, implementation, and maintenance of the intervention. RESULTS Data for 261 patients were analyzed (preintervention, n = 142; post intervention, n = 119). The postintervention period was associated with a higher proportion of patients who were referred to (40% vs 12%; P < .001) and completed (24% vs 10%; P = .003) cardiology follow-up within 7 days of hospital discharge (reach) compared with the preintervention period. After adjustment, the postintervention period was associated with a reduced hazard of the 30-day composite end point (HR, 0.59; 95% CI, 0.37-0.96; P = .04) (effectiveness). CONCLUSIONS The intervention succeeded in increasing referral to and completion of cardiology appointments within 7 days of discharge. In adjusted analysis, the intervention was associated with lower risk of 30-day all-cause ED visits, all-cause hospitalizations, or death.