In the United States, the average annual direct and indirect cost of cardiovascular disease from 2017 to 2018 was estimated to be $378 billion.1 By 2030, the prevalence of heart failure (HF) is likely to exceed 8 million Americans with annual HF care costs estimated to increase to nearly $70 billion.1 These are alarming numbers given the increasing medical complexity of our population, with 5% of individuals having 3 or more chronic conditions.2 In the current healthcare infrastructure, patients tend to move through systems at an expedited pace, having interactions with a myriad of healthcare professionals, technologies, and in various settings, which can be particularly challenging for the complex HF patient population.3 For patients and caregivers, navigating a fragmented healthcare system can be filled with uncertainty, unpredictability, and unmet needs.3

Transitions or “handoffs” between settings prove to be a particularly vulnerable time for individuals. Transitions have been associated with medication discrepancies and errors, miscommunication, unmet needs, and adverse clinical events. For example, roughly 30% of patients experience at least 1 discrepancy between their discharge list of medications versus medications taken home.4 Such inconsistencies contribute to rehospitalizations, overutilization of the emergency department, high healthcare spending, and poor patient experience.5 As a result, Transitions of Care (ToC) programs emerged as a high priority of healthcare reform with the implementation of the Affordable Care Act in 2010, which financially incentivized healthcare systems to focus on value-based care delivery through optimizing care transitions.6 Centers for Medicare & Medicaid Services has supported a variety of ToC-focused projects since this time including Project RED (Re-Engineering Discharge), Project BOOST (Better Outcomes by Optimizing Safe Transitions), the Care Transitions Intervention, and the Care Transitional Model.6–8

Transition of Care programs include 1 or more intervention(s) aimed at improving communication, streamlining the transfer of patient information, and optimizing the care plan to align with “Triple Aim” goals of improving patient experience, improving the health of the population, and reducing healthcare costs.4 Much of the evidence for the effectiveness of ToC programs rests in the transition from hospital to home5; however, transitions can also include patients moving to or from long-term acute care facilities, skilled nursing facilities, or hospice, or shifting from pediatric to adult care teams. Although numerous studies have been published on the impact of ToC program implementation in improving outcomes, there is substantial heterogeneity with respect to included patient populations, types of intervention(s), and outcome measure(s) being evaluated. Despite difficulty in determining which specific intervention(s) are most “impactful” in different patient population(s), there are several evidence-based interventions common across ToC programs. These include (1) identification of high-risk patients, (2) optimizing guideline-directed care before hospital discharge, (3) timely and strategic follow-up appointments scheduled before hospital discharge, (4) telehealth utilization, (5) medication reconciliation, (6) an in-home assessment soon after discharge, (7) a psychosocial assessment and plan to address social determinants of health (SDoH) barriers and psychosocial needs, (8) remote monitoring, (9) streamlined communication pathways between members of the care team, and (10) patient education interventions.4–9 Successful ToC programs incorporate a multimodal, multidisciplinary approach and include a variety of these interventions across the care transition continuum.5,7,9

Providing an equitable ToC program is often not a “one-size-fits-all” approach. Patients with cardiovascular disease and HF are diverse with different comorbid conditions, SDoH barriers, health literacy, and resources. Therefore, a variety of interventions is the most effective way to increase access.10

Consider patient accessibility to care. Intuitively, telehealth interventions increase accessibility. However, this is not true for all patient populations, such as those who live in technology deserts. Close follow-up throughout the transition care pathway that is timed appropriately, ideally less than 1 week from discharge. Medication reconciliation process soon after discharge may be a part of the interdisciplinary team model, including pharmacy support. Screening for SDoH and assessing mental health due to the significant burden that chronic illness can have on mental well-being.11 In addition, it is important to consider and address barriers related to SDoH. One such program that can serve as a ToC model for addressing health equity barriers is the Grady Heart Failure Program. Started in 2011, the program includes a multidisciplinary, multipronged approach to supporting patients with HF at a high risk for readmission. The program addresses socioeconomic barriers to care including but not limited to transportation assistance, mobile integrated health, and assistance with medication access.12 Finally, it is important to consider the long-term plan when intervening in those first 30 days post discharge and “link” patients with appropriate resources in a timely manner.

The Affordable Care Act emphasized the importance of moving toward value-based care. Transitions of Care programs strive to improve the quality of care while reducing readmissions and unnecessary emergency department visits. Still relatively novel in healthcare, it will be imperative to continue to invest in ToC frameworks through research, policy, and clinical practice. Evidence from successful ToC programs highlight the importance of patient education, medication management, remote monitoring and telehealth utilization, multidisciplinary collaboration, assessment of SDoH interventions, and close postdischarge follow-up. These interdisciplinary programs contribute to reduced hospitalization, emergency department utilization, improved patient experience, and lowered healthcare spending. By adopting evidence-based approaches in creating or adopting ToC program models, healthcare systems can help cardiac patients navigate the critical journey from hospital to home. With the ongoing focus on value-based care, along with emerging technologies to enhance care delivery in the home, nursing is perfectly positioned to lead these efforts and should remain a critical component of any ToC program. In addition, social work is integral in the ToC space due to their expertise in navigating complex systems, ability to approach challenging conversations, and ability to provide comprehensive (emotional and logistical) support.11 Finally, when implementing any new program, it is important to use implementation science frameworks to ensure accurate results, minimize bias, and ensure reliability of findings in improving patient outcomes.13 Publishing outcomes after ToC program implementation in a variety of care settings contributes to the expanding body of knowledge in this space—leading to further research, policy, and funding support for these programs.

Nursing Implications

The profession of nursing combines a unique acquisition of skill sets making nurses ideal professionals to implement, manage, and optimize ToC programs. With a high level of direct patient interaction, nurses serve as the primary communicator of health information and coordinators of care services. Collaborating on care plans for best patient outcomes, nurses nimbly navigate amidst a complex healthcare ecosystem to recognize care gaps and advocate on behalf of the patient and family. These skills allow nurses to excel in bridging gaps in care coordination and communication that are essential in the ToC space. Finally, literature supports nurse- and advanced practice nurse–led models to deliver high-quality, high-value care transition programs.

REFERENCES 1. Tsao CW, Aday AW, Alamarzook ZI, et al. Heart disease and stroke statistics—2022 update: a report from the American Heart Association. Circulation. 2022;145(8):e153–e639. https://doi.org/10.1161/CIR.0000000000001052. 2. Blumenthal D, Anderson G, Burke S, Fulmer T, Jha A, Long P. Tailoring Complex-Care Management, Coordination, and Integration for High-Need, High-Cost Patients [discussion paper]. Washington, DC: National Academy of Medicine; 2016. https://nam.edu/wp-content/uploads/2016/09/tailoring-complex-care-management-coordination-and-integration-for-high-need-high-cost-patients.pdf. 3. Ski CF, Cartledge S, Foldager DR, et al. Integrated care in cardiovascular disease: a statement of the Association of Cardiovascular Nursing and Allied Professions of the European Society of Cardiology. Eur J Cardiovasc Nurs. 2023;22(5):e39–e46. https://doi.org/10.1093/eurjcn/zvad009. 4. Parry C, Johnston-Fleece M, Johnson M, Shifreen A, Clauser S. Patient-centered approaches to transitional care research and implementation: overview and insights from patient-centered outcomes research institute's transitional care portfolio. Medical Care. 2021;59:S330–S335. doi:10.1097/MLR.0000000000001593. 5. Naylor MD, Shaid EC, Carpenter D, et al. Components of comprehensive and effective transitional care. J Am Geriatr Soc. 2017;65(6):1119–1125. doi:10.1111/jgs.14792. 6. Li J, Du G, Clouser JM, et al. Improving evidence-based grouping of transitional care strategies in hospital implementation using statistical tools and expert review. BMC Health Serv Res. 2021;21:35. doi:10.1186/s12913-020-06020-9. 7. Albert N, Barnason S, Deswal A, et al. Transitions of care in heart failure: a scientific statement from the American Heart Association. Circ Heart Fail. 2015;8(2):384–409. https://doi.org/10.1161/HHF.0000000000000006. 8. Chang A, Rising K. Cardiovascular admissions, readmissions, and transitions of care. Curr Emerg Hosp Med Rep. 2014;2(1):45–51. doi:10.1007/s40138-013-0031-5. 9. Rochester-Eyeguokan C, Pincus K, Patel R, Reitz S. The current landscape of transitions of care practice models: a scoping review. Pharmacotherapy. 2016;36(1):117–133. doi:10.1002/phar.1685. 10. Sieck CJ, Sheon A, Ancker JS, Castek J, Callahan B, Siefer A. Digital Inclusion as a social determinant of health. NPJ Digit Med. 2021;4(1):52. doi:10.1038/s41746-021-00413-8. 11. White-Williams C, Rossi LP, Bittner VA, et al. Addressing social determinants of health in the care of patients with heart failure: a scientific statement from the American Heart Association. Circulation. 2020;141(22):e841–e863. doi:10.1161/cir.0000000000000767. 12. Centers for Disease Control and Prevention. Field notes: Grady Heart Failure Program. cdc.gov. Accessed August 7, 2023. 13. Harden SM, Smith ML, Ory MG, Smith-Ray RL, Estabrooks PA, Glasgow RE. Re-aim in clinical, community, and corporate settings: perspectives, strategies, and recommendations to enhance public health impact. Front Public Health. 2018;6:71. doi:10.3389/fpubh.2018.00071.