TUCSON, AZ— The benefit of early post-discharge hospital followup for heart failure patients was demonstrated in a new approach at the Southern Arizona VA Healthcare System.

The system implemented a new, multidisciplinary, multistrategy heart failure (HF) team approach that included new clinic slots, predischarge nurse visit, providing a blood pressure cuff and scale and cardiologist supervision.

A study team sought to evaluate pre- vs. postintervention and the effect on outcomes in patients hospitalized with HF between Sept. 1, 2010, and May 30, 2013. The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework was used to evaluate the intervention. Results were published in the American Journal of Managed Care.1

For the quantitative evaluation, study authors compared the proportion of patients in both groups who were scheduled for and completed a cardiology appointment within seven days after hospitalization (“reach”). A Cox model was created to evaluate the “effectiveness” of the intervention period on a 30-day composite outcome (i.e., all-cause emergency department [ED] visit, all-cause hospitalization or death). For qualitative evaluation, the team described the adoption, implementation and maintenance of the intervention.

The study analyzed data for 261 patients—142 preintervention and 119 post intervention. Results indicated that the postintervention period was associated with a higher proportion of patients who were referred to (40% vs. 12%; P <0 .001) and completed (24% vs. 10%; P = 0.003) cardiology follow-up within seven days of hospital discharge compared with the preintervention period. After adjustment, the postintervention period was associated with a reduced hazard of the 30-day composite end point (HR, 0.59; 95% CI, 037-0.96; P = 0.04) (effectiveness), the authors noted.

“The intervention succeeded in increasing referral to and completion of cardiology appointments within 7 days of discharge,” the study concluded. “In adjusted analysis, the intervention was associated with lower risk of 30-day all-cause ED visits, all-cause hospitalizations, or death.”

In effect, the intervention period was associated with a 41% lower risk of emergency visits, rehospitalizations or death, according to the study team, which emphasized, “An early follow-up intervention can be successfully implemented, but there needs to be an emphasis on long-term maintenance.”

They further recommended that VA should consider designating clinicians and nurses at every hospital nationwide to be “HF champions” with training in clinical and administrative leadership.


  1. Dev S, Fawcett J, Ahmad S, Wu WC, Schwenke D. Implementation of early follow-up care after heart failure hospitalization. Am J Manag Care. 2021 Feb 1;27(2):e42-e47. doi: 10.37765/ajmc.2021.88588. PMID: 33577160.