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​Our Transitional Care program has significantly improved our continuum of care for Congestive Heart Failure (CHF) patients by decreasing 30-day readmission rates and mortality. We currently have a dedicated team of Nurse Practitioners (NP’s) who perform transitional care interventions with elder patients, 65 years or older, who are hospitalized for heart failure. 

our NP's work in conjunction with Baylor Health Care System to follow up with patients diagnosed with congestive heart failure through home visits and phone calls. NP’s are also heavily involved in discharge planning by consulting with heart failure patients and establishing a rapport with the patient’s family and physician. The patient and their NP, together, review heart failure information packets and set collaborative goals for post-discharge treatment plans. 

Results of the Transitional Care Program to Date

As a result of our interventions, our CHF readmission rates are currently at an average of 9% for the 265 patients enrolled in the program. At 8%, our readmission rates are significantly below the national average of 23%  ​