Heart failure is the cause of nearly 1 million hospitalizations annually.^1,2,3,4 and ⁵ It is the most common discharge diagnosis among individuals aged 65 years and older, accounting for more than 640,000 discharges per year.^4,5,6,7,8,9 and ¹⁰ Readmissions have increased since the advent of the Medicare prospective payment system.¹⁰ The 90-day readmission rates for individuals aged 70 years and older is between 40% and 60%.^2,11

Patients present to the emergency department (ED) expecting relief of their symptoms of heart failure. These patients are evaluated and treated and are then discharged to the outpatient setting or admitted to the hospital as necessary.¹² As many as 80% of those who present have previously been diagnosed with heart failure.¹³ Many of these individuals can be successfully treated in the ED observation unit. This is a cost-saving approach but adds to the responsibility of the ED staff to provide comprehensive discharge planning.¹³ Failure to meet this responsibility will result in repeated admissions to either the ED or the hospital. For those patients who go on to be admitted to the hospital, the assessment of discharge needs and the plan to meet these needs must begin in the ED.

Discharge planning is a process of evaluation of the patient’s needs both during the admission and after discharge. It begins at the time of admission and must be re-evaluated and adjusted as needed several times during
the hospital stay.¹¹ The process involves an assessment of the precipitating factors resulting in the current admission, educational needs, and postdischarge care.^11,14 Discharge planning should involve the patient, all members of the health care team, the family, and any other caregivers with frequent collaboration.^11,14,15 The discharge planning process and the development of the plan should be documented in the patient’s medical record.¹⁴ The final plan should be communicated to the outpatient health care team, including the patient’s primary care physician, because many readmissions occur due to the lack of communication between the pre- and postdischarge health care teams.^10,14,16

A comprehensive, well-executed discharge planning process can prevent unnecessary delays in discharge and ensure that adequate support is available in the outpatient environment.^14,15 Effective discharge planning is necessary to decrease readmissions and is particularly beneficial for the elderly.^14,15 Inadequate discharge planning is linked to early unplanned readmissions.¹⁷ Evidence of an effective discharge plan occurs when subsequent readmissions are not a result of the patient’s or caregiver’s misunderstanding of medications, diet, or exercise instructions.¹⁶ The readmission also must not be related to lack of access to prescribed medications or treatments as a result of functional or financial limitations or psychosocial problems.¹⁶

Individuals who are at an increased risk for readmission need special attention during the discharge assessment and planning. Readmission rates are extremely high among all individuals with heart failure, with approximately 20% readmitted within 1 month of discharge and 50% within 6 months.^3,18,19 and ²⁰ However, as many as 50% of readmissions might be prevented with comprehensive discharge planning and after-discharge follow-up.^11,21,22 Inadequate patient education and nonadherence to the medical plan may account for as many as 40% of the readmissions.²³

Multiple factors have been associated with an increased risk for readmission. The elderly are at particularly increased risk, especially without adequate discharge planning.^21,24 They are often ill-prepared to make the necessary lifestyle changes that can improve outcomes.²⁴ All ages are at increased risk of readmission if they are inadequately prepared as a result of insufficient education and support prior to and after discharge.²¹ Several physiologic risk factors have been identified (Table 11-1). When present, these risk factors indicate a greater chance that the patient will be readmitted to the hospital for care. Patients with these risk factors need increased attention to their discharge readiness.

Other contributing factors have to do with the patient’s self-care measures and the ability to make the necessary lifestyle adjustments. Many patients fail to adhere to the medical plan due to lack of confidence
that it is necessary or will help.²⁵ Many simply do not understand.²⁵ For instance, few patients have the knowledge of how to follow a low-sodium diet.²⁶ Noncompliance with medications and diet can lead to worsening symptoms and subsequent readmissions.^27,28 Butler et al.²⁰ reported that nearly one third of those discharged on an angiotensin-converting enzyme inhibitor (ACEI) stop taking them within 1 year. Delays in seeking medical care can also result in unnecessary readmissions.²⁸