Grant: Partnerships for Health System Improvement (PHSI)

Heart failure (HF) is a serious condition that occurs when the heart does not pump or fill normally. It is the most common cause of hospitalization in older adults. The month after discharge from hospital represents a vulnerable period during which patients are at increased risk worsening symptoms and death. One in five patients are readmitted during this period, which burdens patients and is expensive to the health care system. Research has shown that certain discharge-planning services can reduce both readmissions and death after hospitalization. However, these services are not routinely offered at hospitals because they require coordination across health care settings and professionals, which is a challenge in health care systems. In this study, we will group together several proven-effective discharge-planning services into 'Patient-centered Care Transitions in Heart Failure' (PACT-HF). This model of care aims to prepare patients for the transition from hospital to home and ensure continuity of care after discharge. Through PACT-HF, patients will benefit from a complete assessment of their health care needs, learn how to recognize and manage symptoms of HF, and receive the information and follow-up care needed to optimize their health. We will roll out the PACT-HF model of care to 16 hospitals over a number of time-periods such that one-by-one, all hospitals will have PACT-HF implemented. We will compare the outcomes of patients in hospitals receiving PACT-HF with those in hospitals not receiving PACT-HF. We anticipate that patients hospitalized at the sites receiving PACT-HF will have fewer readmissions, emergency room visits, and deaths; feel more prepared for discharge; and have a better quality of life after discharge. We also anticipate that PACT-HF will reduce health care costs due to fewer readmissions after hospital discharge.