Regional collaboration among health care systems within the structured Hospital to Home (H2H)  quality improvement initiative is associated with improved seven-day post-discharge follow-up and 30-day readmission rates in heart failure (HF) patients, according to a poster presentation during the 18th Annual Scientific Meeting of the Heart Failure Society of America.

Spearheaded by lead author Joy Pollard, NP, St. Joseph Hospital, Pontiac, the investigation attempted to see if structured collaboration could improve seven-day post-discharge follow-up and reduce HF 30-day readmission rates compared to non-participating hospitals. Between May 1, 2012 and March 30, 2013, 12 urban and suburban area hospitals located in southeast Michigan participated in a multisystem collaborative implementing the “See You in Seven” H2H initiative strategy. Developing a process matrix to identify improvement goals, participating in meetings and webinars, sharing best practices and receiving guidance from national experts, collaborating hospitals submitted gap analyses, improvement plans, and quarterly progress reports.

Results showed that at the end of the research period, the seven-day post-discharge follow-up rate modestly but significantly increased for both collaborating hospitals and non-collaborating hospitals (31.3 to 35.0 percent vs. 29.7 to 32.6 percent, both p<0.003). The overall 30-day readmission rate and the 30-day readmission rate in patients with seven-day post-discharge follow-up was reduced more in collaborating hospitals than in non-collaborating hospitals (overall: 30.2 to 27.3 percent vs. 27.3 to 26.2 percent, p=0.008; seven-day post-discharge follow-up patients: 32.7 to 28.2 percent vs. 29.0 to 26.5 percent, p=0.003). In both groups, the 30-day readmission rate remained slightly higher in patients who attended seven-day post-discharge follow-up than those who did not.

The authors conclude that implementation strategies required a team commitment from both staff and physicians. Moving forward, additional studies are needed to understand the characteristics associated with higher 30-day readmission in seven-day post-discharge follow-up HF patients.

“The Collaborative was able to improve seven-day post-discharge follow-up, and reduce 30-day readmissions,” notes Sandra Oliver-McNeil, DNP, ACNP-BC, CHFN, AACC, Michigan Chapter ACC Cardiovascular Team Liaison. “This project was successful and shows that when we are able to implement best practice is a variety of settings, quality improvement is possible. Each hospital worked on their own process improvement using a variety of resources.”