SHM Converge Scientific Abstract ePoster Gallery-Team-Based Approach to Reduce Readmission in Multi-Visit Patients With Heart Failure

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This project aimed to reduce hospital readmissions among multi-visit patients (MVPs) with heart failure (HF) using a multidisciplinary, team-based approach. The team focused on identifying “drivers of utilization” (DOU) and creating individualized action plans to better address patients’ needs after discharge.<br /><br />The project was motivated by the fact that readmission rates are an important measure of hospital quality, affect reimbursement, and reflect patient care outcomes. In their MVP population, heart failure was one of the most common comorbidities in 2022, so the team targeted this subgroup for intervention.<br /><br />A streamlined review process was developed to assess high-utilization patterns and support transitional care. The multidisciplinary team identified key post-discharge issues and implemented tailored interventions to improve continuity of care. Reported action items included telemedicine to improve follow-up appointment attendance, use of AI to streamline patient education and data collection, and earlier real-time intervention during admission, including optimization of guideline-directed medical therapy (GDMT).<br /><br />Initial results were encouraging. The median readmission rate improved from 50% to 29%, suggesting that the approach may help reduce repeat hospital use in this high-risk population. One notable area for further improvement was patient attendance at follow-up appointments after discharge.<br /><br />Overall, the project concluded that a multidisciplinary, team-based strategy can improve transitional care for MVPs with HF and may help reduce readmissions while supporting more patient-centered care.

Asset Subtitle

Cindy M. Barbosa Nunez

Meta Tag

Author List Cindy M. Barbosa Nunez, Erica Matich, Erin Tammi, Jodi Mullen, John J. Sykes IV, Kevin Peng, Kiran Lukose, Nila S. Radhakrishnan

Category Research

Concept Hospital Readmission

Concept Heart Failure

Concept Readmission Rate

Concept Health Care Utilization

Concept Multi-Visit Patient

Distinguished Non-Finalist

Presenter Organization University of Florida

Presenting Author Cindy M. Barbosa Nunez

Track Quality Improvement

Keywords

heart failure

hospital readmissions

multi-visit patients

multidisciplinary team

transitional care

drivers of utilization

individualized action plans

telemedicine

guideline-directed medical therapy

follow-up appointments

Hospital Readmission

Heart Failure

Readmission Rate

Health Care Utilization

Multi-Visit Patient