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Effective Health Care Program

Transitional Care Interventions To Prevent Readmissions for People With Heart Failure


This CME activity is hosted on the Baylor College of Medicine CME Web site (

Course Overview

Despite an almost 30 percent decline in heart failure (HF) hospitalizations in the United States during the past decade, readmission rates for HF patients have not decreased during the past 2 decades. Readmissions account for an estimated $15 billion in annual Medicare spending. A preventable readmission is defined as one related to the previous admission if there was a reasonable clinical expectation that it could have been prevented by providing quality care during the initial hospitalization, adequate discharge planning, adequate postdischarge followup, or improved coordination between inpatient and outpatient health-care teams.

Studies have suggested that the use of transitional care interventions, such as home visiting, telephone support, telemonitoring, and patient education, might reduce the rate of preventable readmissions. In 2013, the American College of Cardiology Foundation/American Heart Association developed a guideline to address disease management immediately after discharge for HF. However, current clinical practice in the care of adults with HF after hospitalization varies greatly. In addition, uncertainty remains about effective strategies to reduce early readmission rates for these patients. The systematic review summarized in this activity aimed to assess the efficacy, comparative effectiveness, and harms of transitional care interventions for adults with HF.

Educational Objectives

At the conclusion of this activity, the participant should be able to:

  • Discuss the evidence regarding the efficacy, comparative effectiveness, and harms of transitional care interventions that aim to reduce readmissions and mortality for adults hospitalized with heart failure.
  • Distinguish among the similarities and differences of various categories of transitional care interventions for adults with heart failure.
  • Identify gaps in the current evidence base and future research needs regarding the comparative effectiveness of transitional care interventions for adults hospitalized with heart failure.

Target Audience

This CME activity is designed to meet the educational needs of cardiologists, cardiac surgeons, primary care physicians, clinicians (such as nurses, pharmacists, and physical therapists), and case managers who work with patients with heart failure.

Method of Participation

This activity is in PDF and HTML formats and is accompanied by references linked to PubMed abstracts.

To receive a maximum of 0.50 AMA PRA Category 1 Credit(s)™ you should:

  • View the materials in this enduring material.
  • Complete the posttest (you must answer 4 out of 5 questions correctly).
  • Complete and submit the CME registration and evaluation forms.

The estimated time to complete this activity, including review of the materials, is 0.50 hour(s).

Accreditation/Credit Designation

Baylor College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Baylor College of Medicine designates this enduring material activity for a maximum of 0.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Term of Approval

October 2015 through October 2018. Original release date: October 2015

Acknowledgement of Support

This CME activity is supported by a contract, HHSA290201410015C, from the Agency for Healthcare Research and Quality.