Effect of a Post-Discharge Telephone-Based Intervention Led by Social Workers to Reduce Heart Failure Readmissions.

Background: Heart failure (HF) readmission rates at our institution were often higher than the expected levels for our institution type. Social work post-discharge telephone calls were identified as an opportunity to address reasons for HF therapy noncompliance, a major reason for readmissions identified among HF patients at our institution.

Methods: Our study aimed to improve existing post-discharge telephone outreach performed by social workers to reduce 30-day all-cause readmission rates in traditional Medicare patients with HF at a single academic tertiary care hospital. A multidisciplinary team of social workers, nurses, and physicians created 2 HF-specific forms based on an online resource (Target: HF telephone form) provided by the American Heart Association. The first form focused on HF transition of care-related issues, while the second form focused on HF patient education. These HF-specific forms replaced a generic checklist used by social workers during their post-discharge outreach.

Results: Fifty-one patients were included in the intervention. The mean age was 76.82 years old. Most patients were male (56.9%), White (82.4%), Hispanic (58.8%), and spoke English as their preferred language (54.9%). Pre-intervention, the 30-day all-cause readmission rate ranged from 7.1% to 30.8%. Post-intervention, the 30-day all-cause readmission rate ranged from 8.3% to 25.0%. The pre-intervention mean 30-day all-cause readmission rate was 15.5% with a standard deviation of 8.1%, whereas the post-intervention mean was 16.8% and a standard deviation of 5.3% (P = .721).

Conclusions: HF-specific structured telephone support by social workers post-discharge did not reduce 30-day all-cause readmission rates in an elderly, traditional Medicare population with HF.