During exacerbations of Congestive Heart Failure (CHF), older patients may receive care in multiple settings; often resulting in fragmented care and poorly-executed care transitions. The negative consequences of fragmented care lead to duplication of services; inappropriate or conflicting discharge instructions, medication errors, patient/caregiver anxiety, and increased costs of care. In light of changes in Medicare reimbursement penalizing hospitals with above set limits for heart failure (HF) readmissions, models of care are being evaluated for their effectiveness in satisfying this change as well as reducing fragmented care in this population. This paper reviews the Transitional Care Model created by Dr. Mary Naylor at the University of Pennsylvania (Penn Nursing Science, 2013). This model in introduces a patient-centered interdisciplinary team intervention designed to improve transitions across care settings.
Congestive Heart Failure
Congestive heart failure (CHF) is a condition in which the heart is incapable of adequately pumping blood throughout the body or unable to stop blood from backing up into the lungs. The most common cause of CHF is hypertension, previous myocardial infarctions, disorders of the heart muscle or the valves of the heart, and chronic lung diseases such as asthma or emphysema. CHF is a common diagnosis for individuals sixty five years and older. With the growing population of baby boomers, the rate of CHF is predicted to nearly double over the next forty years and will be a drain on healthcare resources. Treatment costs are estimated around $20 to $40 billon, with $8 to $15 billion spent on hospitalization alone (Quaglietti, Edwin, Ackerman, & Froeliher, 2000).
One in four patients hospitalized for CHF are re-hospitalized within thirty days of discharge. This high rate of readmission has brought negative attention from researchers and policy makers and prompted hospitals to implement initiatives aimed at reducing hospital readmissions for CHF patients. Hospital readmissions are a target of quality measurement and performance-based incentives as they are often thought to be attributed to substandard care, such as poor resolution of the presenting problem and inadequate discharge planning during the initial hospital stay.
CHF is the most frequent diagnosis at initial discharge that results in readmission. In 2009, Medicare began publicly reporting hospitals risk-standardized, all 30 day readmission rates among fee-for-service beneficiaries discharged after heart failure hospitalization from all United States acute care hospitals. That same year the average 30 day readmission rate for Medicare patients diagnosed with CHF was 21.2 %. Readmission rates six months post discharge are estimated around 44 %. Noncompliance with medication contributes to 65 % of patients admitted with exacerbation of CHF. It has been estimated that one quarter to one third of...