Transitions of Care Between Acute and Chronic Heart Failure: Critical Steps in the Design of a Multidisciplinary Care Model for the Prevention of Rehospitalization.
Despite advances in the treatment of heart failure, mortality, the number of readmissions, and their associated health care costs are very high. Heart failure care models inspired by the chronic care model, also known as heart failure programs or heart failure units, have shown clinical benefits in high-risk patients. However, while traditional heart failure units have focused on patients detected in the outpatient phase, the increasing pressure from hospital admissions is shifting the focus of interest toward multidisciplinary programs that concentrate on transitions of care, particularly between the acute phase and the postdischarge phase. These new integrated care models for heart failure revolve around interventions at the time of transitions of care. They are multidisciplinary and patient-centered, designed to ensure continuity of care, and have been demonstrated to reduce potentially avoidable hospital admissions. Key components of these models are early intervention during the inpatient phase, discharge planning, early postdischarge review and structured follow-up, advanced transition planning, and the involvement of physicians and nurses specialized in heart failure. It is hoped that such models will be progressively implemented across the country.
Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Programa Integrado de Atención a la Insuficiencia Cardiaca, Área Integral de Salud Barcelona Litoral Mar, Servicio Catalán de la Salud, Barcelona, Spain; Grupo de Investigación Biomédica en Enfermedades del Corazón, Programa de Investigación en Procesos Inflamatorios y Cardiovasculares, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain. Electronic address: josepcomin@gmail.com.
Josep
J
Comín-Colet
Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Programa Integrado de Atención a la Insuficiencia Cardiaca, Área Integral de Salud Barcelona Litoral Mar, Servicio Catalán de la Salud, Barcelona, Spain; Grupo de Investigación Biomédica en Enfermedades del Corazón, Programa de Investigación en Procesos Inflamatorios y Cardiovasculares, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain.
Cristina
C
Enjuanes
Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain; Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain.
Josep
J
Lupón
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, United States; Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States.
Miguel
M
Cainzos-Achirica
Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Programa Integrado de Atención a la Insuficiencia Cardiaca, Área Integral de Salud Barcelona Litoral Mar, Servicio Catalán de la Salud, Barcelona, Spain; Grupo de Investigación Biomédica en Enfermedades del Corazón, Programa de Investigación en Procesos Inflamatorios y Cardiovasculares, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain.
Neus
N
Badosa
Programa Integrado de Atención a la Insuficiencia Cardiaca, Área Integral de Salud Barcelona Litoral Mar, Servicio Catalán de la Salud, Barcelona, Spain; Grupo de Investigación Biomédica en Enfermedades del Corazón, Programa de Investigación en Procesos Inflamatorios y Cardiovasculares, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain; Centro de Atención Primaria Sant Martí de Provençals, Instituto Catalán de la Salud, Barcelona, Spain; Instituto de investigación de Atención Primaria Jordi Gol, Instituto Catalán de la Salud, Barcelona, Spain.
José María
JM
Verdú
D000208:Acute Disease; D000359:Aftercare; D002908:Chronic Disease; D019091:Critical Pathways; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D020380:Needs Assessment; D010347:Patient Care Planning; D010348:Patient Care Team; D010359:Patient Readmission; D012944:Social Support; D013030:Spain; D000069341:Transitional Care / Q000458:organization & administration*
Cuidados transicionales; Heart failure units; Hospital admission; Hospitalización; Integrated management; Manejo integral; Transitional care; Unidades de insuficiencia cardiaca