Background: A major problem facing the U.S. healthcare system is avoidable hospital readmissions. Patients with Heart Failure (HF) face variety of barriers to health care and are at higher risk for readmissions. To address this problem, evidence-based interventions focused on safe transition from hospital to home are needed.
Methods: A quality improvement pilot project was implemented to evaluate the feasibility of evidence based interventions in preventing avoidable readmissions. The project setting was in a 900 bed health care system. The descriptive statistical methods were means and frequencies. The Transition Coordinator (TC) enrolled a convenience sample of 30 participants. The evidence based interventions were Project RED (Re-Engineered Discharge) and the TC Advocacy Plan. Project RED has 12 elements to improve the hospital discharge process by reducing rehospitalization rates, promoting safety, and increasing patient satisfaction. The TC Advocacy Plan consisted of screening tools, HF education, teamwork, collaboration, and use of resources. It offered different strategies and interventions that strengthen the initiatives in avoiding readmissions. This initiative was supported by a collaborative team that included physicians, nurses, social workers, and pharmacists.
Results: Project RED 12 elements and the TC Advocacy Plan were all implemented. The identified trends in data were presented to key stakeholders. This possibly led to an enhanced multidisciplinary collaboration creating continuity of care in patient\u27s seamless transition from inpatient to outpatient settings.
Conclusion: An intervention that incorporates Project RED and the TC Advocacy Plan may be effective in preventing avoidable readmissions, but further investigation is needed
