Coordinated UCSF Medical Center team cuts HF readmission rates by 46%

UCSF's HF program involves comprehensive teach back, home visits

The University of California-San Francisco (UCSF) Medical Center slashed heart failure (HF) readmission rates over a two-year period by 46% within 30-days of discharge and by 35% within 90 days among Medicare beneficiaries, according to a case study from The Commonwealth Fund.

  • Learn eight imperatives for reducing preventable cardiovascular rehospitalizations through discharge planning, transitional and post-acute care, and disease management in the Cardiovascular Roundtable's study, Reducing Preventable Readmissions.

UCSF in 2008 collaborated with the Institute for Healthcare Improvement and received funding from the Gordon and Betty Moore Foundation to implement its HF readmission program.

USCF Medical Center hired program coordinators to provide enhanced patient education and follow-up care connections to promote Medicare patients' successful transition from the hospital to a home or skill nursing facility.

Douglas McCarthy, senior research advisor at The Commonwealth Fund, notes that the program involved:

  • A comprehensive and tailored teach back program;
  • Follow-up phone calls;
  • Alternative options for patients who cannot see a primary-care physician; and
  • Home visits for very high-risk patients.

Moreover the multidisciplinary program was staffed with:

  • A cardiovascular service line director, cardiologists, hospitalists, ad primary-care physicians (PCPs);
  • Two HF nurse coordinators, clinical nurse specialists, outpatient nurse practitioners, and home care nurses;
  • Case managers;
  • Social workers;
  • Pharmacists;
  • Dieticians;
  • Educators; and
  • Skilled nursing facility staff.

In addition, McCarthy notes that the hospital established a virtual care team. "They use email in a creative way to let everyone in outpatient care, including PCPs, know where their patients are at and when they were discharged so everyone is in the loop. This helps [patients] not come back unnecessarily" (Brimmer, Healthcare Finance News, 11/26).

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