Implementing a transitional care program for high-risk heart failure patients: findings from a community-based partnership between a certified home healthcare agency and regional hospital.

Provisions within the recently passed health reform law provide support for new approaches to reducing the high cost of care for clinically complex patients. This article describes the characteristics of a recent transitional care pilot initiative that aims to reduce hospital readmissions among high-risk heart failure patients. The program was designed and implemented through a joint collaboration between a Certified Home Healthcare Agency and regional hospital. As a preliminary assessment of the impact of this program on patient outcomes, we compare the odds of rehospitalization among patients who received the transitional care services (n = 223) and a similar group of patients who received usual home care services (n = 224). Analyses indicated that patients who received the transitional care services were significantly less likely to be readmitted to the hospital than the patients in the control group. Although preliminary, our findings suggest that providing transitional care services to high-risk heart failure patients can be an effective deterrent against patterns of rehospitalization. The opportunities and challenges associated with implementing this pilot program are discussed.