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May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e968

CLINICAL STATEMENTS AND GUIDELINES

involved. Patients are at highest risk for decompensation requiring readmission in the days and weeks post-hospital discharge.13 Optimal transitions of care can decrease avoidable readmissions and improve patient satisfaction.14 Multidisciplinary systems of care that promote improved communication between health care professionals, systematic use and monitoring of GDMT, medication reconciliation, and consistent documentation are examples of patient safety standards that should be ensured for all patients with HF transitioning out of the hospital.

Recommendation-Specific Supportive Text

1.	 HF disease management programs can help to organize the patient’s care across settings. Potential team members may include cardiologists, primary care clinicians, HF nurses, pharmacists, dieticians, social workers, and community health workers. A Cochrane systematic review of 47 RCTs of disease management interventions after hospital discharge found that interventions that use case management (case manager or nurse coordinates care for high-risk patients) or multidisciplinary approach may decrease all-cause mortality and rehospitalization.3 Disease management programs may comprise education, self-management, medication optimization, device management, weight monitoring, exercise and dietary advice, facilitated access to care during episodes of decompensation, and social and psychological support.14 Disease management programs coordinated by HF specialists, including HF nurses, may be best suited for patients with HFrEF; however, there are far fewer data on the effectiveness of disease management programs in patients with HFpEF.2

2.	 Although hospitalizations for worsening HF are often characterized by rapid changes in medical, surgical, and device therapy to optimize a patient’s clinical status, the patient’s journey with achieving optimal HF care continues beyond hospital discharge. Written discharge instructions or educational material given to the patient, family members, or caregiver during the hospital stay or at discharge to home should address all of these: activity level, diet, discharge medications, follow-up appointment, weight monitoring, cardiac rehabilitation, and what to do if symptoms worsen.14 Thorough discharge planning that includes special emphasis on ensuring adherence to an evidence-based medication regimen is associated with improved patient outcomes.15,16 Details of the hospital course and the transitional plan of care, with special attention to changes in medications and new medical diagnoses, must be transmitted in a timely and clearly understandable form to all of the patient’s clinicians who will be delivering follow-up care (Table 25). Any changes in prognosis that will require appropriate care coordination and follow-up postdischarge should be noted. 3.	 Systems of care designed to support patients with HF as they move through the continuum of care can improve outcomes.7,14,17,18 Real-time feedback on performance measure benchmarks can improve use of evidence-based therapy and quality of care.8 Quality improvement programs designed to increase the prescription of appropriate discharge medications can increase GDMT prescription at discharge and decrease readmissions and mortality.9 Electronic point-of-care reminders to prescribe GDMT in patients with HFrEF can improve use.10,19 Leveraging transparent health care analytics platforms for benchmarking and performance improvement may be helpful. There are ongoing studies to determine the most effective strategies to improve evidence-based care.20 4.	 Early outpatient follow-up, a central element of transitional care, varies significantly across US hospitals.11 Early postdischarge follow-up may help minimize gaps in understanding of changes to the care plan or knowledge of test results and has been associated with a lower risk of subsequent rehospitalization.11,12 Transition of care interventions have often bundled timely clinical follow-up with other interventions, making it challenging to isolate any unique intervention effects.21 A structured contact with the patient within 7 days of hospital

Table 25.  Important Components of a Transitional Care Plan A transitional care plan, communicated with the patient and their outpatient clinicians before hospital discharge, should clearly outline plans for: Addressing any precipitating causes of worsening HF identified in the hospital; Adjusting diuretics based on volume status (including weight) and electrolytes; Coordination of safety laboratory checks (eg, electrolytes after initiation or intensification of GDMT); Further changes to optimize GDMT, including:

Plans for resuming medications held in the hospital; Plans for initiating new medications; Plans for titration of GDMT to goal doses as tolerated; Reinforcing HF education and assessing compliance with medical therapy and lifestyle modifications, including dietary restrictions and physical activity; Addressing high-risk characteristics that may be associated with poor postdischarge clinical outcomes, such as:

Comorbid conditions (eg, renal dysfunction, pulmonary disease, diabetes, mental health, and substance use disorders); Limitations in psychosocial support; Impaired health literacy, cognitive impairment; Additional surgical or device therapy, referral to cardiac rehabilitation in the future, where appropriate; Referral to palliative care specialists and/or enrollment in hospice in selected patients. GDMT indicates guideline-directed medical therapy; and HF, heart failure.

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