Transition Care Program: Where We Are and How We Go

The American Heart Association (AHA) scientific statement entitled “Transitions of Care in Heart Failure” addresses recommendations for research and clinical practice regarding transitional care programs to enhance patient-centered outcomes based on available evidence.

Heart failure (HF) is one of the main causes of death in developed countries. The number of patients with HF is estimated to be approximately 5.1 million in the United States, and the prevalence continues to rise with more than 650,000 newly diagnosed cases annually. Hospitalization rates due to HF have not changed in several decades. Aging population leads to an increase in the number of patients with chronic HF. The incidence of HF increases with age and is more than 80 per 1000 individuals among those ≥85 years of age. The survival rate of HF patients has improved in recent decades by use of neurohormonal drugs, such as ACE inhibitors and beta-receptor blockers. However, the mortality rate for HF within 5 years of diagnosis remains approximately 50%. Furthermore, the risk for all-cause readmission of patients hospitalized for HF is high, and the 30-day rehospitalization rate is 25%. The hospitalization rates have not decreased. The rate of rehospitalization is not being attenuated although health care services after discharge are increasing.

To prevent the worsening of the disease, all patients with HF should have a clear, detailed and evidence-based global plan of care which is based on well-understood characteristics of individual patients. Recently, most interventions are started immediately after admission to hospital and continued for varying time periods after hospital discharge. The annual total cost for the care of HF exceeds $30 billion in the United States, and over half of the cost is spent on hospitalizations. Development of effective care plan is essential and urgent to improve clinical and economical outcome.

Some interventional trials have been carried out from the 1990’s to verify the effectiveness of HF management for the prognosis of chronic HF. As a result, it is reported that eight characteristics are important for the improvement of prognosis, such as patient education, telephone follow-up, early follow-up after discharge, early assessment following hospital admission, medication reconciliation, inclusion of caregivers, home visits, and hand-off to post-hospital providers. In patients with HF, the most successful programs in reducing rehospitalization were those that included home visits alone or in combination with telephone follow-up calls. To implement those, transitional care, most often from hospital-to-home and provided by members from various fields, such as medical doctors, nurses, pharmacists, dieticians, patients themselves and their family members, has a crucial role. Although transitional care is ranked as Class I in the guideline for the management of HF, not many hospitals can actually carry out specific services or programs associated with transitional care. To make transitional care more standard for patients with chronic HF, further research focused on both clinical and economical effectiveness is needed. To build upon prior research, key components of effective transition of care programs should be established, such as right population, intervention, study, design, and outcomes.

The plan of transition care should be upgraded regularly and made accessible to not only doctors and patients but also all other members of each patient’s healthcare team. Education, support and involvement of patients with HF, their families and caregivers are important, especially during transitions of care. Indeed, because those are often complex, the rates of HF 30-day rehospitalization and mortality become high if they fail to understand main symptoms of HF, especially acute exacerbation and following a detailed plan of care. From this point of view, most intervention programs highlight the importance of identifying key people who become a caregiver after discharge of patients. Nurses are expected to provide important information to patients about medication management, self-monitoring of symptoms and consultation in the early stage of worsening. Leaders who deliver self-care education to patients are registered nurses, and care programs that used registered nurses actually improved mortality and rehospitalization outcomes. Although this has not been highly considered, it is also an important point that the level of nurses’ understanding of self-care principles must match patients’ needs. Patients know what to do but need assistance in learning how to do it. Thus, leaders of care transition programs must note that nurses recognize how big the gaps of knowledge are between them and patients and how much the care meets the patients’ needs, in addition to whether nurses receive ongoing education. Proper designation of a central leader is critical for success of the program.

In summary, the scientific statement provides specific and valuable issues and improvement for transitional care interventions, especially from hospital-to-home in terms of research and clinical practice for patients with HF. It emphasizes that not only patients but also health care providers, including medical experts such as nurses, should be well educated and that the providers should give patient-centered interventions, such as education and assistance that match patient needs in order to improve the outcomes of patients with HF.