• Brett D Stauffer, Cliff Fullerton, Neil Fleming, Gerald Ogola, Jeph Herrin, Pamala Martin Stafford, and David J Ballard.
• Institute for Health Care Research and Improvement, Baylor Health Care System, 8080 North Central Expressway, Ste 500, Dallas, TX 75206, USA. Brett.Stauffer@BaylorHealth.edu
• Arch. Intern. Med. 2011 Jul 25; 171 (14): 1238-43.

BackgroundRandomized controlled trials have demonstrated the efficacy of nurse-led transitional care programs to reduce readmission rates for patients with heart failure; the effectiveness of these programs in real-world health care systems is less well understood.MethodsWe performed a prospective study with concurrent controls to test an advanced practice nurse-led transitional care program for patients with heart failure who were 65 years or older and were discharged from Baylor Medical Center Garland (BMCG) from August 24, 2009, through April 30, 2010. We compared the effect of the program on 30-day (from discharge) all-cause readmission rate, length of stay, and 60-day (from admission) direct cost for BMCG with that of other hospitals within the Baylor Health Care System. We also performed a budget impact analysis using costs and reimbursement experience from the intervention.ResultsThe intervention significantly reduced adjusted 30-day readmission rates to BMCG by 48% during the postintervention period, which was better than the secular reductions seen at all other facilities in the system. The intervention had little effect on length of stay or total 60-day direct costs for BMCG. Under the current payment system, the intervention reduced the hospital financial contribution margin on average $227 for each Medicare patient with heart failure.ConclusionsPreliminary results suggest that transitional care programs reduce 30-day readmission rates for patients with heart failure. This underscores the potential of the intervention to be effective in a real-world setting, but payment reform may be required for the intervention to be financially sustainable by hospitals.

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