A Transitional-Care Model to Reduce Readmissions After Heart Failure?

High rates of unplanned readmissions after hospitalization for heart failure (HF) and some countries' policies to strengthen financial accountability for these events have prompted a focus on the care delivered in the transition from hospital to home. Observational data suggest that early follow-up after HF hospitalization can lower rates of readmission. The Patient-Centered Care Transitions in HF (PACT-HF) consists of a formal needs assessment, self-care education, patient-centered discharge summary, primary care follow-up within a week, and referral to nurse home visits and a HF clinic for patients at highest readmission risk. To assess the impact of this service model, researchers conducted a cluster-randomized, stepped-wedge trial (NCT0…