UCSF: Transition-to-home program cuts heart readmissions by 30%

A University of California, San Francisco, program aimed at helping hospitals transition patients to their homes reduced hospital readmissions of older heart failure patients by nearly a third, according to a UCSF press release last week.

UCSF's Heart Failure Program showed that only 16 percent of the hospital's heart failure patients were readmitted within a month after discharge, down from 23 percent in 2006. The national average for 30-day readmission is 25 percent.

That difference of 40 patients who were not readmitted, the hospital says, saved Medicare $1 million per year, as well as freed up beds for other patients and kept patients happier at home instead of in the hospital.

"The biggest challenge has been breaking down all the silos to create a continuity of care," said Eileen Brinker, UCSF nurse coordinator, in the press release.

Nurse coordinators, a multidisciplinary heart failure team, and other health providers in the community work together after the patient's discharge. In addition, the program focuses on a teach-back method in which providers explain disease management instructions to patients and ask them to repeat it back to them before leaving the hospital.

Another study by Harvard University last month indicated that informing patients can cut readmissions by nearly 20 percent. According to the Agency for Healthcare Research and Quality, 4.4 million preventable readmissions occur each year.

For more:
- check out the UCSF press release