A study of Charlottesville-based University of Virginia Health System's program to give follow-up care for heart failure patients after leaving the hospital showed significant improvements in survival rates and reductions in readmission length.
The study looked at participants in UVA's Hospital-to-Home, or H2H program, from January 2011 to December 2014. Participants had follow-up visits with two nurse practitioners specializing in heart failure for 30 days after their discharge from the hospital.
Patients usually have an in-person visit with one of the program's NPs within a week of leaving the hospital. The NPs work with UVA physicians, pharmacists and others to evaluate patients' heart failure symptoms and lab results, tailor their medications and suggest lifestyle adjustments.
In the first 30 days after their discharge from UVA, program participants had a 41 percent lower mortality rate and a 24 percent reduction in the length of their hospital readmission compared to nonparticipants.
The study authors found these improvements happened despite H2H participants being sicker than nonparticipants.
Since heart failure is a chronic disease, ongoing management of each patient's care is crucial to ensuring good outcomes, said study author Sula Mazimba, MD.
"It's important to have a program that follows patients closely and especially during their most vulnerable period following a discharge from the hospital. In this regard, a discharge from the hospital is not really a final goodbye, but rather just another phase of their care," Dr. Mazimba said.