A comprehensive transitional care program for heart failure is associated with reduced 30-, 60-, and 90-day hospital readmissions and emergency department visits

Abstract Background: Heart failure (HF) is a leading cause of morbidity and mortality, and short-interval hospital readmissions and emergency department (ED) visits often stem from inadequate post-discharge follow-up. Connecting Care to Home (CC2H), a transitional care program supporting patients with HF during the first 4 weeks after discharge, was launched. The primary outcome was a 30-day composite of hospital readmissions or ED visits; secondary outcomes were these events at 60 and 90 days. Methods: In this retrospective study (August 2018–January 2024), patients with HF enrolled in a 28-day transitional care program were provided with individualized care plans, education, in-person assessments, remote monitoring, a 24/7 line, and coordinated follow-up. They were compared with matched controls receiving standard discharge planning. Matching was based on the Health-Based Allocation Model Inpatient Group score. Results: Among 511 matched pairs, program enrolment was associated with 38% lower odds of the composite 30-day outcome (odds ratio [OR], 0.62; 95% CI, 0.47–0.83, p < 0.001; number needed to treat [NNT] = 11). Similar benefits were observed at 60 days (OR, 0.64; 95% CI, 0.50–0.83, p < 0.001; NNT = 10) and 90 days (OR, 0.66; 95% CI, 0.51–0.84, p < 0.001; NNT = 10). Hospital readmissions and ED visits were each reduced in the intervention group. Conclusion: A structured transitional care program combining multidisciplinary support, patient education, and timely follow-up was associated with substantial reductions in short-term hospital readmissions and ED visits among patients with HF, with benefits persisting to 90 days. These real-world data support broader implementation within integrated health care systems to reduce acute care utilization and improve patient-centred outcomes.