SHM Converge Scientific Abstract ePoster Gallery-Optimizing Heart Failure Management: A Multidisciplinary Approach to Reducing Readmissions

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This quality improvement project evaluated a multidisciplinary heart failure intervention aimed at reducing readmissions by improving guideline-directed medical therapy (GDMT) at discharge and ensuring timely outpatient follow-up. Conducted over 8 months using the PDSA framework, the project included 167 patients hospitalized for heart failure exacerbation at a safety-net hospital serving a population with low health literacy and high comorbidity burden. Of these patients, 57% had heart failure with reduced ejection fraction (HFrEF). The median age was 65 years, and the average length of stay was 3 days.<br /><br />Interventions included GDMT initiation and optimization, extra diuretic prescriptions at discharge, pharmacist-led medication reconciliation, and ensuring follow-up within 30 days. These were reinforced with resident workstation posters outlining tasks for the first three hospital days and EMR reminders to providers. Process and outcome measures were reviewed monthly.<br /><br />After implementation, compliance with GDMT prescription at discharge improved from 38% to 65% among HFrEF patients. GDMT at discharge was strongly associated with lower readmission risk. In contrast, patients who missed their follow-up appointments were 48% more likely to be readmitted than those who attended.<br /><br />Overall, the project showed that a structured, multidisciplinary approach can improve heart failure management, increase adherence to GDMT, enhance post-discharge follow-up, and reduce the risk of readmission, especially in patients with HFrEF.

Asset Subtitle

David R. Serrano

Meta Tag

Author List Ahmed Eisa, Ayesha Tariq, Bolaji Elutilo, Daniel Sittler, David R. Serrano, Enyioma Nwogwugwu, Esther Adedibu, Han Oo, Hanna Andargie, Ho Yin Henry Chan, Jiwon Park, Lida Avetisyan, Mariana Nunes Ferreira, Nana Ama D. Amankwa, Ronaldo Hernandez Gutie

Category Innovations

Concept Heart Failure

Concept Heart Failure with Reduced Ejection Fraction

Concept Guideline-Directed Medical Therapy

Concept Multidisciplinary Quality Improvement

Concept Hospital Discharge

Distinguished Non-Finalist

Presenter Organization NYCHHC/lincoln Hospital

Presenting Author David R. Serrano

Track Quality Improvement

Keywords

heart failure

readmission reduction

guideline-directed medical therapy

multidisciplinary intervention

hospital discharge

outpatient follow-up

HFrEF

medication reconciliation

quality improvement

PDSA framework

Heart Failure

Heart Failure with Reduced Ejection Fraction

Guideline-Directed Medical Therapy

Multidisciplinary Quality Improvement

Hospital Discharge