General description of procedure, equipment, technique

Transition to home from hospital

The time of discharge from the hospital after an admission for an exacerbation of heart failure (HF) is one of the great challenges for patients and their families as they attempt to make the successful transition from the hospital environment where they have no responsibility for their own care, to their homes, where they will be totally responsible for their own care. This challenge is formidable.

Health care providers commonly do not adequately prepare patients for discharge and do not provide them with the skills and knowledge needed to manage their care at home. They often discharge patients too early without adequately assessing their readiness for discharge, and do not provide for early enough follow-up after discharge.

The pressure on health care providers to discharge patients as quickly as possible is intense. Over the past 2 decades, hospital length of stay for heart failure has decreased. Unfortunately, this decrease in hospital length of stay has been accompanied by a substantial increase in the number of patients who are discharged to an extended care facility instead of home, and an increase in 30-day readmission rates. These data suggest that the push to reduce length of stay has not been accompanied by the use of strategies to ensure patients are adequately prepared for discharge.

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The purpose of this chapter is to provide recommendations to health care providers so that they can assist their patients with heart failure to make a successful transition from the inpatient to outpatient setting.

Indications and patient selection

Managing discharge

Every patient who is being discharged from a hospitalization for HF exacerbation should be managed as described to make a successful transition from inpatient to outpatient. In all cases, the person or persons who assist and support the patient with their heart failure should be included in preparation for discharge. Very few patients are able to manage their heart failure without the assistance of family members, friends, or other informal caregivers. Thus, these vital caregivers must also be included in preparations for discharge.


There are no contraindications to adequate preparation of a patient to make the transition from inpatient to outpatient.

Details of how the procedure is performed

Promoting optimal transition from the inpatient to outpatient setting requires attention to three major areas: (1) determining that patients meet criteria for discharge; (2) providing patients and informal caregivers with the information and support needed to assume responsibility for their own care once home; and (3) ensuring vigilant, coordinated follow-up of the patient once discharged.

1. Determining that patients meet criteria for discharge

The heart failure guidelines from the Heart Failure Society of America provide the following criteria for discharge: (a) factors precipitating admission haven been addressed; (b) fluid status is optimized; (c) the transition from intravenous to oral diuretics has been made successfully; (d) patient and family have completed necessary education; (e) chronic outpatient drug therapy is optimized or near-optimized; and (f) have a follow-up appointment scheduled within 7 to 10 days.

a. Factors precipitating admission

In the search for factors precipitating admission, the most common factors should be considered. Across a number of studies, the following have emerged as common factors resulting in admission for a HF exacerbation:

  • Patient nonadherence to diet or medications, or failure to obtain follow-up care

  • Renal insufficiency or failure

  • Myocardial ischemia

  • Infection

  • Medication changes with inadequate follow-up

  • Hypertension

  • Dysrhythmias

  • Anxiety/depression/poor social support

  • Alcohol or drug abuse

  • Poor follow-up care

  • Diabetes

In addition to diagnostic testing to determine medical causes, it is essential that the practitioner carefully question the patient and family about the events leading up to admission to determine the contribution of nonadherence and psychosocial causes to admission. Given that patient nonadherence is the most common cause of admission, it is tempting for clinicians to “blame” the patient. Clinicians must remember that the most common cause of nonadherence is failure of health care providers to provide patients with the information, skills, and support that they need to be adherent.

b. Optimization of fluid status

In most cases, patients admitted with an exacerbation of HF suffer from substantial fluid overload. Yet, it is common for patients to be released from the hospital having experienced minimal or no weight loss, only to be readmitted soon after discharge. This cause of readmission is completely preventable by close attention to fluid status (using accurate daily weights, and fluid balance calculations) and adjustment of diuretics to achieve weight loss consistent with elimination of fluid overload. Clinicians need to determine their patients’ dry weights so that they have a realistic idea about each patient’s optimal fluid status.

c. Transition from intravenous to oral diuretics

At least 24 hours should elapse from the time of transition from intravenous to oral diuretics before discharge in order to determine if the transition has been successful. Weight should continue to be lost and the patient should remain stable and symptom free. Discharge home soon after making the transition to oral diuretics without having time to see that the patient’s response is adequate is a common cause of readmission.

d. Patient and family have completed necessary education

What is considered “necessary” education is controversial. This is most likely because time for education is limited in the hospital, education has never been a priority, and few clinicians are adequately trained to provide excellent patient education.

In addition, hospitalized patients are often fatigued, anxious, and feeling unwell, and as a result are less likely to retain information they are given. Nonetheless, patients cannot be released home without some fundamental knowledge or skills.

It is essential that patients and their informal caregivers understand which medications and what doses they are to take. Education on this topic must include the following at a minimum: (1) written list of medication to be taken; (2) explanations about medications to be discontinued (never assume that not writing them on the discharge medication list is sufficient to keep patients from taking older medications); (3) information about the importance of each medication and how to take it; (4) how to monitor for symptoms of worsening HF (although this seems very easy to health care providers, many HF patients simply are unable to recognize their own symptoms) and when to call the health care provider; (5) how to follow a low sodium diet; and (6) how to manage other co-morbidities.

Health care providers must ensure that plans are in place for their patients in order to optimize postdischarge outcomes. For example, when daily weights are recommended to follow fluid status, does the patient have a scale or can they get one?

Can they read or get on the scale they have? Can they afford any new medications that they have been prescribed? Will they be going home alone, and if yes, can they truly manage alone? Do they have active comorbidities that can interfere with HF management and are there plans in place to manage these comorbidities? Have other health care providers been informed of the patient’s status and has care been coordinated among them?

Many patients can benefit from one or more visits from a home health nurse after discharge and telephone follow-up within a few days of discharge to continue necessary education. In fact, it is important that education be continued as one-time education sessions are inadequate to prepare patients for long-term self-care.

e. Chronic outpatient drug therapy is optimized or near-optimized

Given the high risk for rehospitalization if outpatient drug therapy is not optimized and the risk of adverse events when patients are discharged with instructions for changing doses of medications at home, it is important for clinicians to work on optimization of drug therapy while the patient is hospitalized. Many HF cardiologists believe that patients with advanced HF and frequent hospitalization have better outcomes if the patient’s outpatient drug regimen is optimized and they are on stable doses for 24 hours prior to discharge.

One effective way to determine how symptomatic patients are on given doses of medication is to assess their functional status while you are walking with them in the hospital hall. The vast majority of clinicians assess functional status while the patient is lying in bed and as a consequence, many patients who are symptomatic with activity are missed, and drug therapy is not appropriately optimized. Proper assessment of functional status is essential to optimization of therapy.

f. Have a follow-up appointment scheduled within 7 to 10 days

The first week to 10 days following discharge from the hospital for an exacerbation to HF constitutes a time of great vulnerability for many patients with HF. Many patients do not understand their drug regimen, even after receiving written instructions.

Many patients continue taking discontinued medications, do not take new medications, or do not fill new medication prescriptions. Problems with functional ability are more evident once patients are home and begin to resume regular activities.

Many patients don’t understand how to follow a low salt diet, or how to monitor for symptoms. Thus, it is imperative that an appointment for follow-up of the exacerbation of HF be schedule no later than 10 days after discharge. If a follow-up appointment is scheduled early, problems that could lead to rehospitalization can be picked up and rehospitalization prevented.

2. Providing patients and informal caregivers with the information and support needed to assume responsibility for their own care once home

Always identify the informal caregivers for each patient and include them in education and counseling sessions. Information about what specific knowledge and skills patients and informal caregivers need to engage in effective self-care at home is available from an American Heart Association scientific statement, which is available online from the American Heart Association website.

Self-care recommendations advocated for patients with HF include:

  • Taking all medications as prescribed

  • Following a low sodium diet

  • Monitoring for changes in symptoms and acting early when symptoms increase

  • Remaining active

  • Stopping smoking and restricting alcohol intake

  • Managing comorbidities

  • Obtaining flu vaccines and engaging in other preventive care

  • Navigating the health care system effectively and dealing with communications from multiple providers

This list includes many activities that are quite difficult and that clearly require continued education and support from the health care provider. Referral of patients and their informal caregivers to available HF services or HF disease management programs is an excellent way to increase the support and education they receive. Using such services, patients remain under the care of their primary healthcare provider, but they receive supplemental, intensive care from HF specialists.

Patients commonly need substantial support to become and remain adherent to their medication regimen. Adherence decreases with time in most HF patients.

In one of our studies, we found that the most common reasons that people were nonadherent with their medications was because they continued to follow their old medication regimen after hospital discharge and because they did not understand how to follow the new one (even though all received a written medication list).

Other common reasons were that they received conflicting advice from different health care providers and finances prevented them from buying their medications. These reasons for nonadherence underscore the importance of intensive education and support. Below are some facts that the health care provider must keep in mind when supporting patients and some strategies known to increase patient adherence.

  • Knowledge is necessary but not sufficient to achieve medication compliance.

  • Engage the patient to undertake a greater personal role (self-care) in managing his or her heart failure.

  • Identify the patients able to self-dose, and teach these patients how to medicate with diuretics based on changes in body weight.

    Use once daily dosing whenever possible.

    Consider providing preprepared pill dispensers or teaching patients how to use pillboxes to facilitate their remembering to take medications regularly. Talk to informal caregivers about their preparing pillboxes for patients if appropriate.

    Assess potential barriers to medication compliance such as lack of knowledge, memory problems, finances, and beliefs or values that are inconsistent with medication-taking behavior. Make sure that all pill bottles are labeled in large print with the drug name and dosing regimen.

    Provide patients with an updated medication list at each visit and ask them to tell you what pills they are taking and how often to uncover misconceptions about their regimen.

    Do not assume that patients are taking all of their medicines all of the time. Be open to hearing about problems and working through solutions. Ask, “are you having trouble taking any of your pills regularly?” instead of asking “you take all your pills regularly, right?”

Additional resources are available from OPTIMIZE-HF (Organized Program To Initiate life-saving treatMent In hospitaliZEd patients with Heart Failure) to assist in the discharge-planning process and support patients and caregivers. These resources include a (1) heart failure discharge summary checklist; (2) “Dear Doctor Letter” for the referring physician; and (3) take-home packet for patients on what to do if symptoms worsen, dietary information, and advice on reading food labels, and other education information. This resource packet is available at

Other important resources to support patients and caregivers are available from the Heart Failure Society of America. A series of education modules are available for clinicians to download and give to patients, or for patients to download.

There are modules on “Taking Control of Your Heart Failure,” “How to Follow a Low Sodium Diet,” “Heart Failure Medicines,” “Self-Care: Following Your Treatment Plan and Dealing with Your Symptoms,” “Exercise and Activity,” ‘Managing Feelings About Heart Failure,” “Tips for Family and Friends,” “Lifestyle Changes: Managing Other Chronic Conditions,” “Advance Care Planning,” “Heart Rhythm Problems,” and ‘How to Evaluate Claims on New Heart Failure Treatments and Cures.” These are available from

3. Ensuring vigilant, coordinated follow-up of the patient once discharged

This final goal is often unmet in the current health care system, but use of a transitional care model of care (in which this goal is met) has been found to reduce healthcare costs, reduce rehospitalizations and improve other outcomes in vulnerable high risk patients, including those with HF. Transitional care is the process of ensuring coordination and continuity of healthcare during the many transitions that patients experience as they traverse the healthcare system.

Although there have been many variations of the transitional care model tested, the following characteristics have been demonstrated to be important for good outcomes: (1) coordination of each patient’s care by an advanced practice nurse or highly trained nurse who assists the patient and family as they transition from hospital to home, and across other segments of the healthcare system; (2) coordination of care among the patient’s multiple health care providers with assurance of communication among them; (3) inclusion of the patient and family in decision-making about care; (4) home visits supplemented by phone contact with patient access to the nurse by phone on a 24 hour, 7 days per week basis; and (5) promotion of active involvement of the patient and family in the patient’s care by delivering self-care education and support at a level understandable by the patient.

Although not all health care providers will have access to such programs, it is increasingly common for home health agencies and hospitals to have incorporated aspects of the transitional care model into their services. Health care providers should refer their HF patients, particularly those at risk for rehospitalization, to such programs when available. Clinical practices with multiple providers can hire an advanced practice nurse into the practice to assist in the care of high-risk patients with HF by using the transitional care model.

Ultimately, whatever method clinicians choose to use in managing their HF patients at risk for rehospitalization, it is essential that patient follow-up be frequent, and that patients have easy access to a knowledgeable person in the office who can offer concrete advice about what to do with escalating symptoms and problems or questions with medications.

It is also essential that all of the patient’s care providers communicate with each other to ensure that care is coordinated and patient advice and recommendations are consistent. Achievement of this goal will reduce patient readmission rates and improve their quality of life.

Interpretation of results


Performance characteristics of the procedure (applies only to diagnostic procedures)


Outcomes (applies only to therapeutic procedures)

Data from the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan) trial demonstrated that even in the context of a clinical trial with use of evidence-based therapy and close follow-up, rehospitalization rates are high—at 1-year, 58% of patients in EVEREST were rehospitalized. Early rehospitalization after discharge for an exacerbation of heart failure remains common.

Up to 25% of patients are readmitted within 30 days. The cause of most rehospitalizations is failed self-care (e.g., medication or diet nonadherence). The most common reason for poor self-care is the failure of health care providers to give patients the support, skills, and knowledge they need to engage in effective self-care.

Thus, the goal of providing optimal support for the patient making the transition from inpatient to outpatient is to reduce the high rate of rehospitalization by not discharging patients until it is appropriate to do so and by promoting optimal self-care abilities in patients and families or other informal caregivers. If clinicians can meet this goal, they can expect decreased 30-day and longer-term readmission rates, fewer emergency department visits, and fewer emergent office visits.

Alternative and/or additional procedures to consider

If an inpatient HF service exists or there is a HF disease management program available, strongly consider referral of patients to these services as soon as possible. Some HF disease management programs will see patients while they are still hospitalized, assisting in the transition from inpatient to outpatient.

Many hospitals are now instituting HF services that are managed by nurses in order to decrease the number of HF readmissions that occur within 30 days of discharge. These services are usually free to patients.

Complications and their management


What’s the evidence?

Lainscak, M, Blue, L, Clark, AL. “Self-care management of heart failure: Practical recommendations from the patient care committee of the Heart Failure Association of the European Society of Cardiology”. Eur J Heart Fail. vol. 13. 2011. pp. 115-26. (A resource for self-care strategies)

Lindenfeld, J, Albert, NM, Boehmer, JP. “HFSA 2010 comprehensive heart failure practice guideline”. J Card Fail. vol. 16. 2010. pp. e1-194. (These heart failure guidelines provide self-care recommendations.)

Moser, DK, Doering, LV, Chung, ML. “Vulnerabilities of patients recovering froman acute exacerbation of heart failure”. Am Heart J. vol. 150. 2005. pp. 984(The article documents the marked impairments seen in many patients upon hospital discharge from an exacerbation of heart failure, and the many problems they have with self-care very early after discharge.)

Naylor, MD. “Advancing high value transitional care: The central role of nursing and its leadership”. Nursing Administration Quarterly. vol. 36. 2012. pp. 115-126.

Naylor, MD, Aiken, LH, Kurtzman, ET. “The care span: The importance of transitional care in achieving health reform”. Health Aff (Millwood). vol. 30. 2011. pp. 746-754.

Naylor, MD, Bowles, KH, McCauley, KM. “High-value transitional care: Translation of research into practice”. J Eval Clin Pract. 2011. (These articles include discussion of outcomes of use of specific transitional care models.)

Riegel, B, Moser, DK, Anker, SD. “State of the science: Promoting self-care in persons with heart failure: A scientific statement from the American Heart Association”. Circulation.. vol. 120. 2009. pp. 1141-1163. (This is the first scientific statement to focus on promotion of self-care in patients with heart failure. It provides important information about how to provide the appropriate skills and knowledge. Additional information about specific skills and knowledge needed by patients is available from the Heart Failure Society of America heart failure guideline, which is available online from the website of the Heart Failure Society of America.)