Team-Based Initiative Reduces Readmission for Heart Failure Patients


The Patient Navigator Program reduced readmission for heart attack or heart failure patients by 81.3%.

Hospitals may successfully reduce the readmission rate among patients with heart failure (HF) using the American College of Cardiology’s (ACC) Patient Navigator Program, according to a presentation at the ACC 2017 scientific session.

Hospitals are at risk of incurring large fines due to excessive readmissions for patients, including those who have experienced a heart attack or who have HF. In response to the change implemented by the Centers for Medicare and Medicaid Services, the ACC created the Patient Navigator Program to use a team-based approach to prevent readmissions.

Through the program, hospitals will receive support in creating new or improving processes to reduce readmissions and improve patient care, according to the ACC. The Patient Navigator Program’s goals are to address challenges faced by patients during and after hospital stay, create approaches to make hospitalization less stressful and the recovery period more supportive, and create team-based strategies to reduce readmissions.

In 1 study, the authors analyzed results from Montefiore Medical Center’s initiation. A Navigator Team, which includes a nurse and a pharmacist, provided patient education, scheduled follow-up appointments, and therapy recommendations to 51 patients with HF.

The investigators discovered that this approach reduced readmissions by 81.3%, going from 25.6% to 4.8%, according to the study. This initiative also was observed to increase the education and follow-up received by patients.

“We are excited to see how our data, especially the early post discharge appointment, was adopted by the Hospital Readmissions Reduction program at Montefiore Medical Center, across all three campuses in the Bronx,” said researcher Ketherine DiPalo, PharmD.

Patient readmission can be caused by numerous reasons, including worsening of original symptoms, development of new symptoms, stress from hospitalization, patient frailty, or a lack of understanding of discharge instructions. Elderly patients are especially at-risk of being readmitted to the hospital.

The Patient Navigator Program aims to address the issues that cause readmission to improve patient health and outcomes.

“It takes a commitment by hospitals, including hiring of FTE’s as support staff as Navigator Program Leaders, and dollars to achieve significant results,” said Ileana Pina, MD, MPH.

Additional studies from various locations are needed to determine the value of the program and if it should be expanded to include more hospitals.

“The results are encouraging but preliminary,” said Kim A. Eagle, MD, MACC, editor-in-chief of “We need more data to truly estimate the precise level of benefit of this wonderful program.”

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