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Service Delivery Innovation Profile

Transition Home Program Reduces Readmissions for Heart Failure Patients

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The Transition Home for Patients with Heart Failure program at St. Luke's Hospital in Cedar Rapids, IA, incorporates a number of components to assure patients a safe transition to home or another health care setting. These components include an ongoing enhanced assessment of postdischarge needs, thorough patient and caregiver education, patient-centered communication with subsequent caregivers at handovers, and a standardized process for postacute care followup. The program reduced the 30-day heart-failure-to-heart-failure readmission rate for patients from 14 to 6 percent, and the all-cause heart failure readmission rate is 15 to 17 percent.

See the Description section for several updates related to ongoing assessment and patient education; the Results section for updated data on readmission rate and patient satisfaction; and the Planning and Development section for new information about spread to other conditions and an Advance Medical Team pilot (updated February 2013).

Evidence Rating (What is this?)

Moderate: The evidence consists of a before-and-after comparison of heart failure readmission rate within 30 days.
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Developing Organizations

St. Luke's Hospital
Cedar Rapids, IA
St. Luke's Hospital, part of Iowa Health System, developed this innovation in conjunction with Transforming Care at the Bedside, a joint project of the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement.end do

Date First Implemented


Problem Addressed

Heart failure is associated with high rehospitalization rates, often due to preventable complications resulting from patients' inability to adequately self-manage the condition and poorly implemented transitions to the next care setting. Programs that provide adequate guidance at discharge, appropriate medication management, and appropriate followup with patients during times of transition can reduce readmission rates and improve quality of care.
  • Significant clinical and economic burden: Congestive heart failure (CHF) is the leading cause of hospitalization among older patients; furthermore, heart failure is associated with a substantial economic burden, with costs totaling $29.6 billion in 2006.1
  • Cycle of hospitalization: Almost one-third of heart failure patients are readmitted within 30 days of discharge.1 Although its 30-day heart failure readmission rate of 14 percent in March 2006 was below the national average, St. Luke's Hospital staff believed that this rate could be reduced even further.
  • Causes of rehospitalization: Causes of heart failure rehospitalization indicate a number of factors that could be addressed during the discharge process. These include, but are not limited to, deficiencies in patient self-care education, inappropriate medication reconciliation, poor communication among health care providers between sites of care, and lack of a plan for appropriate medical followup after discharge.2 Hospitalized patients are commonly subject to inadequate discharge processes that lead to clinical deterioration and increase the likelihood of rehospitalization; for example, one survey found that 81 percent of patients requiring assistance with basic functional needs failed to receive a home care referral at discharge, and 64 percent said that no one at the hospital talked to them about self-managing their care at home.3

What They Did

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Description of the Innovative Activity

The Transition Home for Patients with Heart Failure program (designed as part of the Institute for Healthcare Improvement's Transforming Care at the Bedside [TCAB] program) emphasizes early and ongoing assessment of a patient's needs at discharge and incorporates enhanced education and caregiver communication processes. Key elements of the program include the following:
  • Enhanced ongoing admission assessment for postdischarge needs: On admission, the nurses in the medical surgical unit perform a discharge assessment to create an expected discharge plan. Planning for discharge includes the following:
    • Estimating the discharge date: Nurses estimate the patient's discharge date.
    • Designating an accountable clinician: A caregiver whom the patient identifies as wanting to be involved in discharge care planning and education is identified (updated February 2013).
    • Assessing discharge needs: Based on the typical course of CHF care as well as patient-specific needs, nurses predict the needs of the patient on discharge. Considerations include but are not limited to volume status, cognitive status, access to social and financial resources, home setting characteristics, medication and dietary restrictions, recommended activity level, assistive devices required, self-care required, and consideration for referral to home care or to a disease management program. Nurses request information from family caregivers and community providers (e.g., home health nurses, primary care physicians, heart failure clinic nurses) in determining patient needs. The units conduct a daily huddle with the charge nurse, unit case manager, and frontline nurse caring for the patient; goals of care and goals for discharge are discussed and the “patient story” is put together with all the input from those involved in the care (updated February 2013).
    • Reconciling medications: Medications are reconciled on admission. The hospital utilizes specific admission nurses to perform the medication reconciliation (updated February 2013). In addition, a plan for the likely medications required on discharge is developed.
    • Working with other organizations: If the patient will be discharged to a home care agency, a nursing home, or a setting other than home, representatives of these agencies are contacted to inform them of the expected discharge date and to arrange for effective handoff.
    • Adjustment of initial plan: The care team, through the daily huddle and ongoing collaboration, reevaluate the discharge plan daily, adjust the plan of care, and adjust discharge preparations accordingly (updated February 2013).
    • Providing patient-friendly discharge instructions: Instructions include information such as where the patient is going, a list of remaining decisions that need to be made, information about safe and effective use of medications, followup care planned, self-care required, and contact information in case of emergency.
  • Thorough education for patients, caregivers: An enhanced teaching and learning process was implemented to ensure that patients and family members understand discharge instructions, self-care instructions, medications, and other postdischarge issues. Caregivers use the teach-back method in the hospital; home care providers repeat the education in the home, and the clinics use teach-back methods during followup appointments. As part of teaching, caregivers review four main questions with patients related to taking a water pill, describing the eating plan, knowing the signs and symptoms to report to the physician, and monitoring and reporting weight gain. Family caregivers are identified so that education can be provided to both the patient and the caregivers. Education techniques include the following:
    • Using basic communication strategies: Such strategies include speaking slowly; avoiding use of jargon; and using simple, short sentences. In addition, concepts of health literacy are incorporated into the teaching process both in written and verbal communication (updated February 2013).
    • Asking patients and families how they learn best: Nurses provide alternatives such as enhanced education packets with written materials, videos and audiotapes, personalized discussions, and interpretive services.
    • "Ask Me 3": This technique, developed under the umbrella of the National Patient Safety Foundation, emphasizes three critical questions: (1) What is the main problem? (2) What should I do? and (3) Why is it important to do this? Professionals provide information that fits within these three questions.
    • Teach-back methodology: Patients are asked to repeat back educational information provided to confirm their understanding. Gaps in understanding are identified and retaught. St. Luke's has a competency validation for teach-back to ensure reliability of the teaching method in the nursing practice. Teach-back is part of the onboarding for new employees and in the nurse residency program (updated February 2013).
    • Return demonstrations: Patients are asked to demonstrate their ability to perform what was taught; for example, patients may be asked to weigh themselves and record their weight in front of the caregiver.
    • Small segments of critical material repeated frequently: Health topics are broken down into learnable sections (no more than four points at any given time); only essential information—such as use of diuretics and when to call the doctor—is provided (additional education can be provided after discharge). Patients are retaught this information each day to improve recall, with new content added if comprehension seems strong. Written material is provided to reinforce messages and to be used for home reference.
    • Outpatient heart failure class: The hospital implemented a 3- to 4-hour outpatient heart failure class held every other month. The class is highly interactive and emphasizes the educational material at a time when patients are out of the hospital and feeling better.
    • Calendar: A component of the educational program is a calendar that patients use to log their weight; the calendar also includes other information to help patients maintain awareness of critical self-management issues.
  • Patient-centered handover communication: A patient nurse or discharge nurse ensures that clinicians receiving the handover of the patient are provided complete information about the patient's functional and cognitive status, family resources, and care needs, including the medication regimen, self-care needs and abilities, and durable medical equipment needs. Other elements of effective handover include medication reconciliation, written information provided to the patient, and transmission of critical information to the next set of caregivers before discharge.
  • Postacute care followup: All patients are scheduled for a followup visit at 5 to 7 days postdischarge with a physician. This physician office visit is scheduled before discharge (previously, the timing of the followup visit varied by whether the patient was high risk or moderate risk, but now all patients are scheduled within 5 to 7 days). A hospital-based heart failure clinic facilitated by an advanced registered nurse practitioner was opened in August 2011. This nurse practitioner sees patients in the clinic within 3 to 5 days of discharge and works collaboratively with the patient's primary care physician to ensure appropriate management.

Context of the Innovation

St. Luke's Hospital in Cedar Rapids, part of the Iowa Health System, is a 500-bed hospital with more than 17,000 annual admissions. St. Luke's Hospital has approximately 25 to 30 CHF admissions per month. St. Luke's Hospital participated in the TCAB Project, a joint project of the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement, which focuses on improving the quality and safety of patient care on medical and surgical units, increasing the vitality and retention of nurses, improving the patient's/family's care experience, and improving the effectiveness of the care team. St. Luke's had been working on reducing heart failure readmissions since 2005, but chart reviews showed opportunities for further reductions. Representatives of St. Luke's decided to pursue a quality improvement initiative to further reduce readmission rates as part of the TCAB project. Information provided in December 2009 indicates that the program has expanded to the pneumonia/chronic obstructive pulmonary disease population.

Did It Work?

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The program has enabled St. Luke's Hospital to reduce its heart failure readmission rates by more than one-half; specific results include the following:
  • Reduction in readmission rates: St. Luke's hospital reduced its 30-day heart-failure-to-heart-failure readmission rate from 14 percent in March 2006 to 6 percent by March 2007; the improvement has persisted to the present. The hospital also measures all-cause, 30-day readmission rate; as of December 2012, this rate was approximately 15 to 17 percent, down from 23 percent pre-implementation (updated February 2013).
  • Increase in medication reconciliation compliance rate: The rate of compliance with discharge instructions for medication reconciliation, as measured by chart review, increased from a range of 75 to 88 percent in 2006 to an average of 98 percent in early 2007; compliance in the fourth quarter of 2008 was 100 percent. Compliance has remained high thereafter (98 percent).
  • High percentage of home care referrals: Information provided in January 2011 indicated that 82 to 90 percent of the patients discharged home now have a home care referral and at least one visit in the home. A small percentage of the patients refuse the home visit.
  • Rate of correct teach-back responses: Staff used patients' failed teach-back responses to improve teaching methods with regard to symptoms. As a result of further improvements, the percentage of symptoms patients could teach back increased from 67 percent in April 2007 to 88 percent in July 2007. As of December 2009, these rates were 80 percent in the hospital and in the middle 80s in the home, with home care and at the 5- to 7-day followup phone call with the heart failure nurse. As of December 2010, these rates held steady: 80 percent in the hospital and approximately 85 percent in the home, with home care and at the 5- to 7-day followup phone call with the heart failure nurse.
  • High patient satisfaction: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey scores for education are at 87 percent, higher than the national average of 83 percent (updated February 2013).

Evidence Rating (What is this?)

Moderate: The evidence consists of a before-and-after comparison of heart failure readmission rate within 30 days.

How They Did It

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Planning and Development Process

The Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure toolkit outlines the planning and development process adopted by St. Luke's Hospital so that this process can be followed by other adopters. Key steps of this planning and development process are summarized below:
  • Form a team: Form a core team of five to seven people from various medical disciplines and roles (e.g., frontline nurses; nurse managers; pharmacists; discharge planners; rehabilitation therapists; clinic, long-term care, and home care representatives; office/practice staff members; and patient and family).
  • Identify opportunities for improvement: Review and analyze heart failure readmissions to identify failures in the current process. A line chart of the 30-day readmission rate of patients with heart failure was created to track past and future data.
  • Develop an aim statement: The aim statement should be time specific and measurable and should define the specific population of patients that would be affected.
  • Create a basic flowchart of the process: The flowchart should outline the major steps in the current discharge process and the care providers and disciplines involved. Then, flowcharts of subprocesses should be created.
  • Standardize each subprocess and measure its reliability: Standardize the steps in each subprocess and then measure whether and how often staff execute the process for a group of patients.
  • Redesign the process and test changes: Based on the findings from the previous step, redesign each subprocess with the goal of greater reliability. Changes can be refined through several Plan-Do-Study-Act cycles.
  • Measure progress: Establish key performance measures to identify whether changes constitute improvements.
  • Spread the new process: Spread the new process to other shifts or units.
  • Spread to other conditions: Information provided in February 2013 indicates that the initiative is now in the process of being spread to all readmitted patients or high-risk patients.
  • Advance medical team pilot: Information provided in February 2013 indicates that the new process for heart failure is now the core for much of the work involved in any readmission and greater effort is put on care coordination across the continuum. Recently, an advance medical team pilot was initiated for high-risk/complex pulmonary patients; this is based out of the pulmonary clinic but the navigator works closely with hospital partners.

Resources Used and Skills Needed

  • Staffing: No new staff members were hired by the program. Existing staff developed the new program and educational materials and absorbed enhanced teaching responsibilities and other duties into their daily activities.
  • Costs:
    • Followup home care visits for high-risk patients: St. Luke's Hospital covers 60 percent of the home care visit, and the hospital subsidizes the remaining costs.
    • Followup phone calls to discharged patients: Approximately 10 to 15 phone calls are made per month to patients who are discharged home. The cost of the advanced practice nurse's time allocated to this task is approximately $10,000 annually.
    • Educational materials: The refrigerator magnets cost approximately $1 each. St. Luke's Hospital distributes approximately 70 per month, at an annual cost of $840. Information provided in December 2009 indicates that the calendars, a newly-implemented component of the program, cost approximately $1,000 annually.
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Funding Sources

St. Luke's Hospital
St. Luke's Hospital was the funding source; the project received no direct funding from RWJF but did benefit from RWJF support to Institute for Healthcare Improvement through the TCAB program, specifically through faculty who led the program and consulted with St. Luke's during the innovation program.end fs

Tools and Other Resources

Nielsen GA, Bartely A, Coleman E, et al. Transforming care at the bedside how-to guide: creating an ideal transition home for patients with heart failure. A toolkit to help teams implement the innovation. Cambridge, MA: Institute for Healthcare Improvement; 2008. Available at:

Adoption Considerations

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Getting Started with This Innovation

  • Share best practices: Expose teams at the adopting site to teams at other organizations who are also working on reducing heart failure readmissions. Colleagues at other sites can offer suggestions and solutions that can be very helpful.
  • Talk to patients and families: Survey patients and family caregivers to learn about failures in the discharge process and to get ideas for improvements. Track the questions patients ask during postdischarge phone calls to the hospital to gain insight on how discharge efforts might be improved.
  • Confirm who will be the family caregiver: Family visitors at the hospital may not be the people who will have the primary responsibility for caring for the patient after hospital discharge. Identify the patient's actual family caregivers during multidisciplinary rounds by asking who will be helping with care in the home.
  • Ensure excellence in patient education: Base education on well-established patient education tenets, standardize teaching materials, and use teach-back methods to ensure patient understanding. Develop teaching materials in multiple delivery methods, such as written materials, videotapes, and face-to-face discussions.
  • Ensure thorough medication reconciliation and communication: Medication reconciliation should be performed by a qualified clinician. At discharge, patients and families should be provided with a copy of the most recent medication list from the health record along with specific instructions for use of each medication.
  • Standardize appropriate patient followup care: Schedule the patient's post-hospital followup office visit before discharge. Standardize a system of followup phone calls to patients within 48 hours of discharge.
  • Work with clinicians in other settings to ensure optimal patient handoff: Talk with representatives of home care agencies, visiting nurse associations, and skilled nursing facilities to ask how they prefer to receive information and to ensure appropriate design of handoff communication tools, forms, and processes.

Sustaining This Innovation

  • Continue to implement process improvement: The program is being expanded to ensure process improvement in other diagnoses, including coronary obstructive pulmonary disease, pneumonia, and myocardial infarction; program staff also continue to work with the cross-continuum team on improvement in skilled nursing facilities and office practices.
  • Even after the readmission rate goal is achieved, review every heart failure readmission to develop ideas for further improvement: Program developers at St. Luke's Hospital are sustaining program gains and continue to review all readmissions to determine how to continually improve the care process. The team is also now reviewing revisits to the emergency department within 30 days (i.e., the patient visited the emergency department and revisits within 30 days).
  • Incorporate teach-back as a nursing competency: Teach-back has become a competency validation for the St. Luke's nursing staff to assure comfort with the process.

More Information

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Contact the Innovator

Peg Bradke, RN, MA
Director of Heart Care Services
St. Luke's Hospital
1026 A Avenue NE, PO Box 3026
Cedar Rapids, IA 52406-3026
(319) 369-7269

Innovator Disclosures

Ms. Bradke reported having no financial interests or business or professional affiliations relevant to the work described in this profile.

References/Related Articles

Nielsen GA, Bartely A, Coleman E, et al. Transforming care at the bedside how-to guide: creating an ideal transition home for patients with heart failure. Cambridge, MA: Institute for Healthcare Improvement; 2008. Available at:


1 Landro L. Keeping patients from landing back in hospital. Wall Street Journal. December 12, 2007. Available at:
2 Nielsen GA, Bartely A, Coleman E, et al. Transforming care at the bedside how-to guide: creating an ideal transition home for patients with heart failure. Cambridge, MA: Institute for Healthcare Improvement; 2008. Available at:
3 Clark PA. Patient satisfaction and the discharge process: evidence-based best practices. Marblehead, MA: HcPro, Inc.; 2006.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 16, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 24, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 12, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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