Transition of Care Interventions Lower Readmission Rates

Recently, I spoke with Patrick Hefner, a registered nurse and cardiopulmonary case manager at the Charles George VA Medical Center, to learn more about cardiac care for Veterans. Hefner emphasized that effective cardiac care requires a multidisciplinary approach, including medication adherence and healthy dietary choices. 

With over a decade of experience, he has gained deep insight into the complexities of coordinating care for Veterans and noted that one key challenge is helping them recognize when to seek help for heart-related issues.

“Our Veteran population are warriors who can overcome any challenge, but when it comes to heart health, being self-reliant is not enough,” Hefner said. 

He also highlighted the facility’s Transition of Care Clinic as one of the most transformative efforts in place, significantly reducing hospital-wide readmission rates—especially among heart failure patients.

The Western North Carolina VA Health Care System (WNCVAHCS) faced high hospital-wide readmission rates in 2022. According to the Strategic Analytics for Improvement and Learning (SAIL), the facility was ranked in the bottom 40% nationally. Recognizing the clinical and financial burdens associated with repeated hospitalizations, Chief of Staff Dr. Ashfaq Ahsanuddin assigned Dr. Maureen McLaughlin-Grant the task of initiating a program aimed at improving care transitions.

“I asked a Hospitalist to review patients with a lens on the inpatient treatment and the disease-mediated high risk of readmission,” explained Dr. Ahsanuddin. “This helped Dr. McLaughlin-Grant to quickly synthesize a list of patients for focused intervention.”

Multiple avenues of care were able to be brought to bear quickly for a small number of patients in the outpatient setting. “I did not make any 

assumptions about how the care needed to be provided, so I basically asked her to get the plane in the air and then tell me what she needed to make it keep flying,” he added.

Although Dr. McLaughlin-Grant was not an outpatient physician, she successfully established a transition of care clinic focused on high-risk Veterans through proactive interventions.

“At that time, I lacked office space and relied on phone outreach,” Dr. McLauglin-Grant recounted. “However, I quickly found myself overbooking and managing dozens of patients in a single day.” What began as a once-a-week clinic has now expanded to daily operations, facilitating timely in-person follow-ups and reducing reliance on emergency care.

In early 2023, the Chief of Staff incorporated PA Matthew Bell into the transition of care clinic, leveraging his process improvement expertise. Since then, PA Bell has been diligently monitoring and utilizing process improvement methods with data science to streamline operations

The transition of care clinic oversees all high-risk individuals, but it primarily focuses on heart failure because PA Bell found early on during the process improvement project that it is one of the leading causes for hospital admissions and readmissions at this facility, mimicking a national trend.  Each year, the facility typically manages around 600 heart failure patients.

The system that was developed allowed for close monitoring of patients, with follow-up contact made within two business days of hospital discharge to address medication adjustments, symptom management, and appointment adherence by Dr. Mclaughlin-Grant. “The reward of her efforts has been substantial for the patients,” concluded Dr. Ahsanuddin. 

Similarly, PA Bell, who is also a hospitalist at the facility acknowledged: “Her proactive approach was extremely beneficial in preventing patients from returning to the emergency room.”

Values from multiple perspectives

The transition of care clinic has shown remarkable decreases in hospital-wide readmissions, especially among heart failure patients. 

Bell shared that the transition of care clinic has embraced a collaborative strategy focused on patient education about 

Guideline-Directed Medical Therapy.  GDMT, recommended by the American College of Cardiology and the American Heart Association, encompasses clinical evaluation, diagnostic testing, and both pharmacological and sometimes procedural treatments proven to be successful to reduce morbidity and mortality.

“When a patient with heart failure is admitted to the medical center, the healthcare providers will take this opportunity to educate Veterans on the importance of considering GDMT medications,” said Bell.  His findings during the project have shown a substantial decrease in not only Heart Failure readmissions by 36%, but also an estimated reduction in heart failure mortality by 30% since the project began.

This improvement has elevated the facility's ranking from the bottom 40% nationally to the top ten among all VA facilities. 

Beyond operational outcomes, Dr. McLaughlin-Grant has observed notable progress in patients dealing with advanced heart failure. “The other day, I encountered a patient suffering from advanced heart failure who had been readmitted over five times for the same condition in 2022,” Dr. McLaughlin-Grant remarked. “During his visit, I observed that he hasn't been readmitted in a year and a half.”