Two decades ago, heart failure clinics were proposed widely as an effective means of improving care.1 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.”2 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-analyses3, 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.3 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).4 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).4
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-David R. Thompson, PhD, RNa, Chantal F. Ski, PhDa, Alexander M. Clark, PhD, RNb
-This article originally appeared in the March issue of The American Journal of Medicine.
