Effectiveness of Short Term Home-Based Care for Long Term Prevention of Heart Failure Hospitalizations of High Risk Patients

Abstract

Introduction Heart failure is the number one cause of hospital readmissions among Veteran Affairs (VA) patients. We implemented a home-based RN/LPN team to high risk patients who provided short-term, intensive CHF case management in collaboration with a cardiologist. Hypothesis Decline in the number of ER visits, inpatient days and 30-day readmission rates with patients who follow in the home-based HF program when compared six months pre-program, and during and after enrollment. Methods This retrospective study done at the Indianapolis VA Medical Center had 108 CHF patients enrolled in the home-based CHF program from May 2016-September 2017. Data was retrieved from national VA databases as well as the electronic medical record. We compared patients’ acute care utilization six months prior to the program, during the program, six, and twelve months post-program discharge using chi squared test. Results The 30-day readmission rate of the 108 patients closely followed by the care team (average 57 days) was only 7%. This contributed to a significant decrease in readmission overall (7%) compared to prior to initiation of the program (500 HF patients admitted in 2016 with 21% readmission rate, p Conclusions Short-term, intensive home-based teams for high-risk veterans with CHF can reduce ER visits, admissions, 30-day readmissions, and the number of inpatient days and be highly cost-effective. This home-based care model showed significant effect persisting after the formal program/intervention ended, as there was a continued sizable reduction in total inpatient days at six and twelve months post-program discharge.