Transitional Care Interventions for Heart Failure: What Are the Mechanisms?

Two decades ago, heart failure clinics were proposed widely as an effective means of improving care. Despite dozens of trials over subsequent years, it has often been difficult to ascertain the true effectiveness of such programs due to poor descriptions of study populations, interventions, comparators, and outcomes. This is compounded by the use of terms such as "transitional care," "integrated care," "coordinated care," "community care," and "person-centred care." These differences in terminology continue to make drawing conclusions about the effectiveness of interventions difficult. More recent studies refer to "transitional care interventions," defined as "a broad range of time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations , and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another." While this definition overlaps with other forms of established care (primary care, care coordination, discharge planning, disease management, case management), and there is no clear consensus on when the transition period ends, at least this definition is inclusive. Recent systematic reviews of transitional care provide some supporting, though imprecise, evidence. There is consensus as to what interventions should focus on: patient/ caregiver education, medication reconciliation, coordination with outpatient providers, arrangements for future care, symptom monitoring, home visits, telephone support. Of 2 recent systematic reviews and meta-analyses 3,4 of transitional interventions, one found that home-visiting programs and multidisciplinary heart failure clinics reduced all-cause readmission (relative risk [RR] 0.75; 95% confidence interval [CI], 0.68-0.86; RR 0.70; 95% CI, 0.55-0.89, respectively) and mortality (RR 0.77; 95% CI, 0.60-0.997; RR 0.56; 95% CI, 0.34-0.92, respectively) at 3-6 months, and structured telephone support reduced heart failure-specific readmission (RR 0.74; 95% CI, 0.61-0.90) and mortality (RR 0.74; 95% CI, 0.56-0.97) at 3-6 months. This review concluded that these interventions should receive the greatest consideration by health care providers. 3 The other systematic review and network meta-analysis testing the efficacy of transitional care provided beyond 1 month of follow-up found that nurse home visits and nurse case management reduced all-cause readmission (incident rate ratio [IRR] 0.65; 95% CI, 0.49-0.86; IRR 0.77; 95% CI, 0.63-0.55, respectively) and nurse home visits and disease management clinics reduced all-cause mortality (RR 0.78; 95% CI, 0.62-0.98; RR 0.80; 95% CI, 0.67-0.97, respectively). Interestingly, nurse home visits and nurse case management had greater pooled cost savings (US $3810 and US$3435, respectively) than disease management clinics (US$245). These analyses incorporated trials which, though categorized under the broad heading of "transitional care," reported a wide range of heterogeneous interventions. Consequently , the key characteristics of effective interventions cannot be discerned. These components were identified in a systematic review of transitional care strategies and heart failure readmission that identified 8 characteristics integral to improving long-term outcomes: discharge planning; mul-tiprofessional teamwork, communication and collaboration; timely, clear and organized information; medication reconciliation and adherence; engaging social and community support groups; monitoring/managing signs and symptoms after discharge and delivering patient education; outpatient follow-up; and advanced-care planning and palliative and end-of-life care. Finally, a systematic review of the impact of heart failure care systems found that access to a specialist heart failure team/service reduced hospital readmissions and mortality, and that, in the transitional care phase, disease management programs and nurse-led clinics reduced hospital readmissions. Nurses are invariably and inextricably linked with driving all of these activities; consequently, they play a key role, directly and indirectly, in reducing readmission. This evidence, taken as a whole, provides compelling evidence attesting to the value and effectiveness of