Background: Heart failure readmissions have identified an inadequate structured program following discharge. Incorporating transitional care processes has improved patient outcomes and quality care .
Local Problem: A thirty chart audit of heart failure patients was conducted. Only 12 (40%) had documentation that indicated the reason for readmission. Of the 30 patients, three (10%) had documented heart failure education. The aim of this project was to decrease 30-day readmission rates by integrating transitional care tools into Long Term Care (LTC) during a 90-day period.
Methods: Every two weeks, rapid cycle quality improvement using plan-do-study-act cycles were performed. Cycles evaluated team and patient engagement, right care for medication reconciliation, and screening. Data was monitored using run charts.
Interventions: Surveys and tools were provided to promote change. The primary toolkit utilized was the American Heart Associations, Get with the Guidelines – Heart Failure . Team engagement meetings, shared decisionmaking (SDM) processes with patients, screening, and medication reconciliation were implemented.
Results: Routine team meeting attendance was challenging, but staff were engaged at 77%. Right care for heart failure screenings was achieved at 82%, with utilization of the SDM process at 75%, and medication reconciliation was met at 100%. Readmission rates decreased by 75% following a 90-day utilization of the tool.
Conclusion: Implementation of the Get with The Guidelines - Heart Failure toolkit  decreased overall readmission rates. Although improvement in all quality measures were noted, there was concern that some may not continue to be sustained due to staffing and scheduling issues.View pdf