title: Protocol-Driven Allied Health Post-Discharge Transition Clinic to Reduce Hospital Readmissions in Heart Failure.
abstract: BACKGROUND
  Heart failure (HF) patients have high rates of hospitalization and rehospitalization.
  
  
  RESULTS
  A protocol-driven clinic staffed by an allied health care team was designed for patients discharged from the hospital with a diagnosis of congestive HF. The clinic provided follow-up visits 1 week and 4 to 6 weeks after hospital discharge. One-hundred and fourteen patients were observed at least 1 time, and 80% of these patients completed the 2-visit protocol. Clinical evaluations were provided by a nurse practitioner specializing in HF and a clinical pharmacist; these evaluations included physical examination, laboratory evaluation, medical education and reconciliation, medication adjustment and titration, and care coordination. Referrals to home health and appropriate services were provided. At visit 1, 25% of patients were hypervolemic and 13% were hypovolemic. At visit 2, 20% were hypervolemic and 13% were hypovolemic. Medicine reconciliation errors were common, with an average of 2.1 and 0.8 errors per person recorded for visits 1 and 2, respectively. Clinic participants showed a 44.3% reduction in 30-day readmission rates, as compared to the hospital's average 30-day readmission rates.
  
  
  CONCLUSIONS
  Protocol-driven postdischarge transition care delivered by allied health staff addressed multiple transition issues and was associated with a dramatic reduction in readmission rates.
authors.affiliation: Seasons Hospice Care, Houston, TX (E.K.D.).
authors.forename: Erin K
authors.initials: EK
authors.lastname: Donaho
authors.affiliation: Pharmacy Department, Memorial Hermann TMC, Houston, TX (A.C.H., J.A.G.).
authors.forename: Andrea C
authors.initials: AC
authors.lastname: Hall
authors.affiliation: Pharmacy Department, Memorial Hermann TMC, Houston, TX (A.C.H., J.A.G.).
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Gass
authors.affiliation: Texas Heart Institute, Houston, TX (M.A.E., V.V.L., D.E.M.).
authors.forename: Macarthur A
authors.initials: MA
authors.lastname: Elayda
authors.affiliation: Texas Heart Institute, Houston, TX (M.A.E., V.V.L., D.E.M.).
authors.forename: Vei-Vei
authors.initials: VV
authors.lastname: Lee
authors.affiliation: Palliative Care Department, Kelsey Seybold Clinic, Houston, TX (S.P.).
authors.forename: Shreda
authors.initials: S
authors.lastname: Paire
authors.affiliation: Texas Heart Institute, Houston, TX (M.A.E., V.V.L., D.E.M.).
authors.forename: Deborah E
authors.initials: DE
authors.lastname: Meyers
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000488:Allied Health Personnel; D002985:Clinical Protocols; D003266:Continuity of Patient Care; D005260:Female; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data; D062209:Patient Handoff; D010359:Patient Readmission / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D055815:Young Adult
keywords: diuretics; drugs; heart failure; nursing; pharmacy; readmission; transition care