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9.6 Integration of Care: Transitions and Team-Based Approaches
COR LOE
Recommendations
1 B-R 1. In patients with high-risk HF, particularly those
with recurrent hospitalizations for HFrEF, referral to
multidisciplinary HF disease management programs is
recommended to reduce the risk of hospitalization.
1 B-NR 2. In patients hospitalized with worsening HF, patient-centered
discharge instructions with a clear plan for transitional care
should be provided before hospital discharge.
2a B-NR 3. In patients hospitalized with worsening HF, participation in
systems that allow benchmarking to performance measures is
reasonable to increase use of evidence-based therapy, and to
improve quality of care.
2a B-NR 4. In patients being discharged after hospitalization for
worsening HF, an early follow-up, generally within 7 days of
hospital discharge, is reasonable to optimize care and reduce
rehospitalization.
Table 25. Important Components of a Transitional Care Plan
A transitional care plan, communicated with the patient and their outpatient
clinicians before hospital discharge, should clearly outline plans for:
• Addressing any precipitating causes of worsening HF identified in the hospital;
• Adjusting diuretics based on volume status (including weight) and electrolytes;
• Coordination of safety laboratory checks (e.g., electrolytes after initiation or
intensification of GDMT);
• Further changes to optimize GDMT, including :
a. Plans for resuming medications held in the hospital;
b. Plans for initiating new medications;
c. Plans for titration of GDMT to goal doses as tolerated;
• Reinforcing HF education and assessing compliance with medical therapy and
lifestyle modifications, including dietary restrictions and physical activity;
• Addressing high-risk characteristics that may be associated with poor postdischarge
clinical outcomes, such as:
a. Comorbid conditions (e.g., renal dysfunction, pulmonary disease, diabetes, mental
health, and substance use disorders);
b. Limitations in psychosocial support;
c. Impaired health literacy, cognitive impairment;
• Additional surgical or device therapy, referral to cardiac rehabilitation in the future,
where appropriate;
• Referral to palliative care specialists and/or enrollment in hospice in selected patients.
