Protocol-driven allied health post-discharge transition clinic to reduce hospital readmissions in heart failure

Erin K. Donaho, Andrea C. Hall, Jennifer A. Gass, Macarthur A. Elayda, Vei Vei Lee, Shreda Paire, Deborah E. Meyers

Research output: Contribution to journalArticlepeer-review

33 Scopus citations


Background-Heart failure (HF) patients have high rates of hospitalization and rehospitalization. Methods and 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.

Original languageEnglish (US)
Article numbere002296
JournalJournal of the American Heart Association
Issue number12
StatePublished - Dec 1 2015
Externally publishedYes


  • Diuretics
  • Drugs
  • Heart failure
  • Nursing
  • Pharmacy
  • Readmission
  • Transition care

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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