Implementing Multi-Disciplinary Care in a Community Hospital: An Approach to Reducing Heart Failure Readmissions

From the 2021 HVPAA National Conference

Aaron Brooks (Magnolia Regional Health Center), Jennifer Nickol, Abram Arnold, Theodore Richards, Margaret Baker


Congestive heart failure (CHF) has been shown to represent one of healthcare’s largest burdens in terms of cost and patient morbidity and mortality. The Centers for Medicare and Medicaid Services (CMS) has charged hospitals with reducing CHF readmissions in an effort to lower healthcare costs, improve quality metrics, and improve patient outcomes. Although reducing CHF readmissions has become a priority of many hospitals, identifying appropriate solutions remains a challenge for hospitals nationwide and represented a significant source of hospital readmissions for our community hospital in rural Mississippi.


A case management driven multi-disciplinary team was formed to identify patients admitted with a diagnosis of heart failure in an effort to provide meaningful intervention while in the hospital and appropriate transitions of care when the patient left the hospital.


A protocol was developed that was initiated by case management when a patient was admitted to our hospital with symptoms of heart failure. A pre-determined list of heart failure-related diagnosis codes and a list of objective findings were used to identify patients that were then placed on the protocol. Initiating the protocol lead to the patient being seen by a team of cardiac rehabilitation specialists for CHF education and physical therapy for evaluation and treatment. The education provided focused on medication compliance, healthy eating habits, importance and dates of follow-up appointments, daily weighing, and appropriate exercise. The American Heart Association and the Centers for Disease Control developed the educational materials used. After the patient’s discharge, they also received a follow-up phone call from the cardiac rehab team to monitor the patient’s progress, discuss compliance, and screen for symptomatology. This protocol was in place for a 12-month interval with periodic monitoring of readmission rates after the interventions.


The implementation of the multi-disciplinary heart failure protocol in our community hospital led to a reduction in our heart failure readmission rate. In the year prior to implementation of the protocol, the hospital’s overall CHF readmission rate was 25%. Throughout the 12-month period that the protocol was studied, the CHF readmission rate was 6-7%. This led to lower overall healthcare costs, fewer reductions in reimbursements, and better patient care.


CHF readmissions represent a significant problem for not only hospitals but also patients. Effectively treating patients in an underserved, community hospital setting is difficult given lower education and socio-economic status. We developed a successful protocol that improved patient understanding and compliance in an effort to reduce CHF readmissions. Through the implementation of this protocol, our hospital was able to reduce its readmission rates. These changes have been ongoing in our hospital, and we continue to search for further interventions to continue reducing our CHF readmission rate.

Clinical Implications

Implementation of a CHF protocol that includes patient education, physical therapy, and close patient follow-up yielded reduced readmissions among our patient population, which ultimate represents better outcomes and improved quality of life for our patients.

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