Outcomes of a Transitional Care Clinic to Reduce Heart Failure Readmissions at an Urban Academic Medical Center.

Heart Failure (HF) is one of the leading hospital readmission diagnoses in the United States. It is a major challenge in today's healthcare environment to reduce hospital readmissions for HF and much of the expenditure on HF is on in-hospital treatment. In the USA, risk factors for readmission with HF include being African American, low-socioeconomic status, Medicare, Medicaid, self-pay/no insurance and drug abuse. The Transitional Care Clinic (TCC) model established at our institution integrated multiple facets of chronic HF management, including early post-discharge follow-up, phone call reminders as well as clinical pharmacists and nurse practitioner's integration into the treatment team. Of 488 HF admissions to our institution from March 2015 until May 2017, mean age = 65 years (SD 13.03), 262 patients were males (53.6%) and 463 patients (94%) were Blacks. There was a total of 121 readmissions within 30 days after discharge (24.8%) and 43 readmissions 7 days after discharge (8.81%) during our study period. 159 patients (32.58%) followed up in our TCC, while 329 patients (67.41%) did not at TCC. Within 7 days post discharge, there was 3 (1.9%) Vs 40 (12.2%) readmissions for TCC and non-TCC groups respectively, P

心力衰竭（HF）是美国主要的医院再入院诊断之一。在当今的医疗环境中，减少心力衰竭的医院再入院率是一项重大挑战，而且心力衰竭的大部分支出用于住院治疗。在美国，心力衰竭再入院的风险因素包括非裔美国人、社会经济地位低下、医疗保险、医疗补助、自费/无保险以及药物滥用。我们机构建立的过渡护理诊所（TCC）模式整合了慢性心力衰竭管理的多个方面，包括出院后早期随访、电话提醒以及临床药剂师和执业护士融入治疗团队。在2015年3月至2017年5月期间，我们机构共有488例心力衰竭入院患者，平均年龄为65岁（标准差13.03），其中262例为男性（53.6%），463例患者（94%）为黑人。在我们的研究期间，出院后30天内共有121例再入院（24.8%），出院后7天内有43例再入院（8.81%）。159例患者（32.58%）在我们的过渡护理诊所进行了随访，而329例患者（67.41%）未在过渡护理诊所随访。出院后7天内，过渡护理诊所组和非过渡护理诊所组的再入院率分别为3例（1.9%）和40例（12.2%），P（此处似乎内容不完整）