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How Heart Failure Patients Can Reduce Readmissions With Transitional Care


A heart failure diagnosis can be many things — overwhelming, frightening, or even confusing. As patients transition back into their daily lives, they might have questions about how to monitor their condition or what kind of diet or exercise regimen is right for them. While many people are unfamiliar with the concept of a transitional care unit, it can be a positive addition to any wellness plan. 

What Is a Transitional Care Clinic? 

A transitional care clinic (TCC) is a team of medical professionals who work with patients to help them understand their diagnosis and determine healthy lifestyle changes they can make. A patient should make an appointment within a week of leaving the hospital and come with any questions. The team at the TCC will measure stats, like blood pressure and weight, and provide you with the tools you need to manage your condition. 

What Services Does a Transitional Care Clinic Offer? 

When someone is in the hospital due to a cardiac event and receives a heart failure diagnosis, there can be a lot of information to process. Instead of dumping all of this vital knowledge on patients and sending them on their way, the TCC supports them by providing this information in easily digestible doses and making sure each individual truly understands it. 

“When a patient gets admitted to the hospital, they see a nurse navigator or outreach coordinator, and that’s when we do a brief disease education and learn about their health and their social determinants of health,” said Bernie Chance, a nurse practitioner at the Transitional Care Clinic at Baylor St. Luke’s Medical Center

The team also works to develop strategies to improve quality of life and avoid readmission to the hospital. They focus on teaching people how to care for themselves, including what diet they should be eating, how they should exercise, and other tools for maintaining a healthy lifestyle.

“We help them understand that there are other ways to eat and be active,” Chance said. “We guide them down the path to owning their health and having increased health literacy and motivation to take more control.”

The Benefits of Transitional Care for Heart Failure Patients

The benefits of going to a TCC are unparalleled. The team provides patients with disease management tools, teaches them when to call the doctor and when to go to the ER, and gives people time to absorb their diagnosis and get answers.

Prior to discharge, patients see a nurse practitioner who goes over the physician’s discharge plan and medication history. Within 7-10 days, they return for a follow-up appointment where they receive a head-to-toe assessment to ensure there are no infections, fluid build-ups, or other complications. 

The average rate of readmission to the hospital within 20 days of a heart failure diagnosis is 22%, while patients who utilize the Transitional Care Clinic at Baylor St. Luke’s Medical Center have a significantly lower rate of 14%. 

“We want to keep patients out of the hospital so they can be home with their family and so they don’t have to lose work or family time,” Chance said. “Our goal is to curb that trajectory of their health decline and try to improve their health.”

The TCC clinical team is a transitioning navigation team to get patients into a long-term medical home by helping set up appointments with their primary care or specialty care provider, or if they don’t have one, by connecting them to a medical home for long-term care. We offer an appointment at one of our TCCs within seven days of discharge for patients at Baylor St. Luke’s Medical Center and The Woodlands Hospital.

If you or a loved one have recently received a congestive heart failure diagnosis, speak to your St. Luke’s Health cardiologist for more information about scheduling an appointment at our Transitional Care Clinic in The Woodlands or at Baylor St. Luke’s Medical Center. Locate your nearest affiliated emergency room so you know where to go during a serious cardiac event. 

Sources:
FOX 26 Houston | Transitional Care Clinic at Baylor St. Luke's Medical Center 
St. Luke's Health | Transitional Care Clinic at Baylor St. Luke's Medical Center 
St. Luke's Health | Transitional Care Clinic at The Woodlands Hospital

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