Living with heart failure: How to avoid hospital re-admission

The Bottom Line

  • Many people end up back in the hospital after heart failure.
  • Transitional care can help patients with heart failure better manage their condition and avoid repeat visits to the ER.
  • Home visits by health professionals and heart failure outpatient clinics lower the chance of readmission to the hospital and lower the chance of dying within six months after heart failure.
  • Simple telephone support for patient monitoring, education and self-management is also effective and may work well for people living in areas without specialty clinics or services. Ask your doctor about what transitional care options are available to you.

You’ve been rushed to emergency with symptoms of heart failure. You’re treated, given medication and care instructions and prepped to go home. Now that you’re out of immediate danger and the initial shock has worn off you call it a “wake up call” and are grateful for a new lease on life.

Yet, as many as 25% of patients treated and released from the hospital after heart failure are readmitted within 30 days (1). What does it take to help those at risk of repeat heart failure avoid being a frequent visitor to the ER?

Having access to the right type of post-treatment care and support is key.

“Transitional care” is designed to help ensure people continue to get the medical care and attention they need after the transition from hospital to home (2;3). This can include support by a coordinated health care team providing education about self-care, monitoring the patient’s progress and symptoms and offering support to help manage medications (4). Transitional care can be provided through home visits, in a dedicated heart failure clinic, or remotely by telephone, video or internet.

But does this type of care really help keep people out of the hospital after heart failure? If so, which approaches are most effective? That’s what a systematic review of 47 randomized controlled trials sought to find out (4).

The transitional care approaches included: home visiting programs (e.g. follow-up home care delivered by health professionals); structured telephone support; telemonitoring of heart rate, blood pressure and other measures; scheduled visits to heart failure clinics; and patient/caregiver education. Readmission to hospital and rates of death among heart failure patients receiving transitional care were compared to those receiving standard care only.

What the research tells us

Both home visiting programs and heart failure clinics help lower the chance of being readmitted to hospital and lower the chance of dying within six months after heart failure. Patient monitoring, education and self-management through telephone support helped lower the chance of another heart failure event (4;5).

What do you do if you don’t have access to specialty clinics or services? Telephone monitoring and support is adaptable to people in different living situations and locations. Another recommended strategy is to include – and measure the success of – transitional care approaches in primary care settings (4). This could include efforts to ensure patients have increased access to primary care clinics with staff who are equipped with the knowledge and skills to provide targeted support after heart failure. Speaking of staff, nurse-led transitional care appears to decrease heart failure specific hospital readmission and may reduce the length of hospital stays (6). 

The review reinforces the fact that effective follow-up medical care can have an important role in healing and recovery after heart failure, helping patients enjoy that “new lease on life” for a good long time!

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Author Details


  1. Dharmarajan K, Hsieh AF, Lin Z et al. Diagnosis and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013; 309:355-363.
  2. Stauffer BD, Fullerton C, Fleming N et al. Effectiveness and cost of a transitional care program for heart failure: a perspective study with concurrent controls. Arch Intern Med. 2011; 171:1238-1243.
  3. Naylor MD, Aiken LH, Kurtzman ET et al. The care span: The importance of transitional care in achieving health reform. Health Aff (Millwood). 2011; 13:746-54.
  4. Feltner C, Jones CD, Cené CW et al. Transitional care interventions to prevent readmissions for persons with heart failure: A systematic review and meta-analysis. Ann Intern Med. 2014; 160(11):774-784.
  5. Van Spall HGC, Rahman T, Mytton O, et al. Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: A systematic review and network meta-analysis. Eur J Heart Fail. 2017; 19(11):1427-1443. doi: 10.1002/ejhf.765.
  6. Li M, Li Y, Meng Q, et al. Effects of nurse-led transitional care interventions for patients with heart failure on healthcare utilization: A meta-analysis of randomized controlled trials. PLoS One. 2021; 16(12):e0261300. doi: 10.1371/journal.pone.0261300. 

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