P158 - IMPROVING OUTCOMES IN HEART FAILURE: HOW A COMPREHENSIVE TRANSITIONAL CARE PROGRAM DECREASES HOSPITAL READMISSIONS AND EMERGENCY DEPARTMENT UTILIZATION

Background: Heart failure (HF) remains a major contributor to morbidity and mortality, with repeated hospitalizations driven by suboptimal post-discharge follow-up. To address this gap, we implemented a multidisciplinary transitional care program aimed at supporting HF patients during the critical post-discharge period. We aimed to evaluate whether enrollment in a multidisciplinary transitional care program, “Connecting Care to Home” (CC2H), reduces 30-, 60-, and 90-day readmissions and emergency department (ED) visits in patients hospitalized with HF.

METHODS AND RESULTS: This retrospective study was conducted between August 2018 and January 2024 at London Health Sciences Centre. Inclusion criteria required a confirmed HF diagnosis, willingness to participate in a transitional care program, and residence in the local service area; key exclusions included palliative status, dialysis dependence, and conditions limiting meaningful engagement (e.g., advanced dementia). Patients admitted with HF were offered a 30-day transitional care program featuring personalized care plans, patient education, a minimum of three in-person assessments, remote monitoring, a 24/7 telephone support line, and close follow-up with HF specialists and primary care physicians. Enrolled patients were 1:1 matched with non-enrolled controls using the Health-Based Allocation Model Inpatient Group (HIG) score. This matching controlled for illness complexity and resource utilization. The primary outcome was a composite of 30-day readmission or ED visit; secondary outcomes examined these events at 60 and 90 days. Logistic regression evaluated the impact of program enrollment, controlling for the HIG score.
Among matched patients, 17.5% of the CC2H group versus 30.0% of controls experienced the primary 30-day outcome, corresponding to a 37.6% relative reduction (OR 0.62, 95% CI 0.47–0.83, p< 0.001; number needed to treat [NNT]=8). Similar benefit was observed at 60 days (31.7% vs. 41.9%; OR 0.64, 95% CI 0.50–0.83, p< 0.001; NNT=10) and at 90 days (38.2% vs. 48.3%; OR 0.66, 95% CI 0.51–0.84, p< 0.001; NNT=10). Separate analyses of ED visits alone and readmissions alone likewise showed consistent reductions in favor of the transitional care program. Model fit was verified using the Hosmer–Lemeshow test, and sensitivity analyses confirmed robustness across a range of demographic and clinical strata.

Conclusion: A structured transitional care program delivering multidisciplinary support, patient education, and prompt post-discharge follow-up significantly reduces readmissions and ED visits among HF patients, with benefits sustained through 90 days. These findings highlight the value of coordinated supportive care in improving HF outcomes and suggest this approach will potentially reduce healthcare costs for this patient population.