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Table 26. Recommendations for Hospital Discharge
(and Strategies to Reduce Readmissions)
Recommendation COR LOE
Performance improvement systems in the hospital and
early postdischarge outpatient setting to identify HF for
GDMT
I B
Before hospital discharge, at the first postdischarge visit,
and in subsequent follow-up visits, the following should
be addressed:
a. Initiation of GDMT if not done or contraindicated
b. Causes of HF, barriers to care, and limitations in
support
c. Assessment of volume status and blood pressure with
adjustment of HF therapy
d. Optimization of chronic oral HF therapy
e. Renal function and electrolytes
f. Management of comorbid conditions
g. HF education, self-care, emergency plans, and
adherence
h. Palliative or hospice care
I B
Multidisciplinary HF disease-management programs
for patients at high risk for hospital readmission are
recommended
I B
A follow-up visit within 7–14 days and/or a telephone
follow-up within 3 days of hospital discharge is reasonable
IIa B
Use of clinical risk-prediction tools and/or biomarkers to
identify higher-risk patients is reasonable
IIa B
Treatment
