A systematic review of transitional-care strategies to reduce rehospitalization in patients with heart failure.

The objective of this review was to evaluate existing transition-of-care models and identify common themes that may minimize exacerbation and rehospitalization, and improve quality of life for patients with heart failure (HF). HF is a significant burden in the United States and a common reason for recurrent hospitalizations. When multidisciplinary health care providers function as liaisons and educators during transition from hospital to home, they help prepare patients for life with chronic HF and mitigate the need for readmission. Systematic literature searches were performed to identify research papers relevant to transition-of-care themes in HF. Eight common themes were identified that can be applied to patients with HF to improve long-term outcomes. This paper emphasizes ways in which health care providers can implement theme-based transitional care, including providing patients and caregivers with practical skills and services that promote knowledge and engagement in self-care and stimulate active communication with health care providers.