This tool will help you quickly identify potential gaps in hospital, transitional, and post-discharge care for heart failure patients which contribute to potentially preventable readmission.
Discharge Criteria for Patients Hospitalized with Heart Failure
This is a general algorithm intended to assist in the management of HF patients, and delineates the recommended discharge criteria for these patients. This clinical tool is not intended to replace individual medical judgment or individual patient needs.
This is an example of a HF discharge checklist that can be used by hospitals.
Telephone Follow-up Form PDF | Word
This form was designed to help make early follow up on recently discharged heart failure patients easier. Studies have proven that early follow up with patients significantly reduces readmission rates and improves overall quality of life for the patient. This quality improvement tool makes it simple to perform a comprehensive follow up that is comprehensive enough to use on its own or flexible enough to incorporate any addition or deletion of questions as deemed appropriate by the provider.
Review of Readmitted Heart Failure Patients
There are multiple reasons why a heart failure patient may require readmission shortly after their initial heart failure hospitalization. This document helps your team to identify potential gaps in transitional care that contribute to potentially preventable readmissions.
This document is intended to provide a brief rationale as to each of the measures that are measured under Target: Heart Failure for each of the three key categories: (1) Medication Optimization, (2) Early Follow-up Care Coordination, and (3) Enhanced Patient Education. To qualify for the Target: Heart Failure Honor Roll, hospitals must demonstrate 50% or greater compliance on the following measures within those key areas for at least one calendar quarter.
Readmission Fact Sheet
This fact sheet discusses how Target: Heart Failure can help facilitate your hospital’s efforts to improve quality and reduce heart failure readmissions.
30-day Readmission Yale Core Risk Calculator
Heart failure patients are at high risk for early rehospitalization. This risk may vary by patients. Clinical risk tools may help to stratify this risk, such as the Center for Outcome Research and Evaluation (CORE) online readmission risk calculator for heart failure. This fact sheet provides a brief overview of the CORE risk calculator.
Follow-up fact sheet
Studies have found that one of the most effective means of reducing readmission rates for heart failure patients is to employ early follow up practices with the patient. The Target: Heart Failure Follow Up Fact Sheet provides information on the new Telephone Follow Up form and addresses the importance of this quality improvement tool.
The Get With The Guidelines/Target: Heart Failure Enhanced Heart Failure Patient Education Prior to Hospital Discharge fact sheet was developed to explain the importance of patient education and the rationale for why specific information is important to obtain. Patient education is a critical success factor in helping patients manage their heart failure. By ensuring that your hospital has set goals surrounding patient education and has a clear understanding of what information is most important to convey to patients, you can help improve the overall quality of life with those affected by heart failure. This fact sheet is an effective tool in helping your hospital make patient education a priority.