disease management, heart failure, heart failure disease management programs, heart failure rehospitalizations



  1. Willey, Rita M. DNP, FNP-BC, MBA, BSN


Background: Preventing heart failure (HF) rehospitalizations requires examination of evidence-based research, which may lead to opportunities to improve on care transitions upon discharge from an acute care setting. This review was conducted to identify current literature in HF and disease management without focusing specifically on disease management programs.


Purpose: The purpose of this study was to conduct a systematic review of the literature to better understand how to structure interventions for HF patients upon transition from the hospital to home and to outline critical research gaps.


Conclusion: Patients recently hospitalized for HF or at high risk for HF decompensation should be considered for comprehensive heart failure disease management (HFDM) and/or structured HF interventions. Level 1 evidence demonstrated positive benefits from HFDM programs, structured telephone support, and telemonitoring interventions as an effective component of contemporary multidisciplinary HF management.


Clinical Implications: Based on the evidence from this critique, key features and recommendations are provided. Also discussed is the State Action on Avoidable Rehospitalizations program, which may provide acute care centers in Massachusetts an opportunity to create an ideal transition home for HF patients.