Reduction in Re-Hospitalization Rates Utilizing Physical Therapists Within a Post–Acute Transitional Care Program for Home Care Patients With Heart Failure

Abstract

Up to 25% of patients hospitalized with heart failure (HF) are re-admitted within 30 days. The highest risk of re-admission is within the first days after discharge. Transitional care programs usually only involve nurses and physicians. The purpose of this study was to describe a post–acute care program including physical therapists and to evaluate re-admission rates following program implementation. The program provided HF-specific training encouraging nurses and physical therapists to assess HF status and instruct on self-monitoring. Thresholds for communication with medical providers were established. Patient groups before (n = 162) and after implementation (n = 300) were similar. Following implementation, there was a 16% decrease in re-hospitalization with little change in the number of visits. Similar multidisciplinary programs may impact re-hospitalization rates and health care costs for HF.