Rapid Follow-Up Key to Reducing Readmissions for Patients with
Heart Failure

Visit within Three Days Post-Discharge May Avoid Problems

John Bisognano, M.D.

John Bisognano, M.D.

Aiming to reduce readmissions by 25 percent for patients with a primary diagnosis of heart failure, URMC protocol advises that high-risk patients be seen by a care provider within three days of discharge to avoid problems and assure their care is progressing.

Across the country, nearly a quarter of all patients admitted with heart failure are readmitted to the hospital within 30 days, according to John Bisognano, M.D., Ph.D., director of Cardiology Outpatient Services. Those readmissions tend to come in two waves: within the first seven days after discharge, and secondly, between two to three weeks post-discharge. Traditionally, post-discharge follow-up visits have been scheduled with patients’ cardiologists or primary care physicians within that two to three-week period.

By intervening and seeing patients sooner, issues such as medication adjustments and helping patients understand and comply with their discharge plans can help patients stay on track and avoid a return trip to the hospital. Also, barriers to medication adherence at home can be promptly identified and addressed.

“To achieve this goal, our protocol is to advise that patients see a care provider within three days of discharge from the hospital,” Bisognano said. “Recognizing that this may present a scheduling challenge for some physician offices, we have developed a Rapid Heart Failure Clinic as an alternative, to assure that patients can be seen within that timeframe. This care is designed to supplement any visiting nurse services that the patient may also have at home.”

Doctor helping patientThe Rapid Heart Failure Clinic, located in Clinton Crossings, is staffed by cardiac nurse practitioners Carla Edgett and Ronald Beck, both of whom have many years of experience treating patients with heart disease. It is designed to provide short-term, post-discharge follow-up with heart failure patients to identify potential problems early and provide support to patients soon after they’ve gone home. Clinic staff also calls patients at home within a couple days to answer any questions or address any additional issues that arise.

“It’s an extension of their hospital stay, designed to detect problems and make adjustments in support of patients’ progress,” Bisognano said. Patients are seen once or twice in the Rapid Heart Failure Clinic, with additional focus on creating a smooth hand-off to the patient’s cardiologist and/or primary care provider for long-term follow-up.

The Rapid Heart Failure Clinic is available Monday through Friday. Weekend referrals are addressed promptly on Monday mornings and may be made by phone or email hfclinic@urmc.rochester.edu.

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