Project 2: Transitions of Care in Heart Failure | Healthcare Institute for Innovations in Quality


Transitions of Care in Heart Failure

About the Project

Hospitals and other stakeholders are struggling with how to improve the transitions from the inpatient to outpatient setting for heart failure patients. Through interviews with multiple hospitals and outreach to national organizations, the KC QVIC has identified a number of potential strategies hospitals may choose to deploy. A brief description of each is provided. These are intended to supplement, or augment, current initiatives and should be selected based upon the perceived relevance and fit within the organization. We have ordered them into clusters that move from easier to harder to implement, knowing that no intervention is easy to launch. We currently recommend that one or two be selected so that efforts can be directed to improving the success of one initiative before moving on to others.

Through interviews with multiple hospitals and outreach to national organizations, the KC QVIC has identified three key strategies hospitals may choose to deploy: 

CODEHF: Patients with heart failure who have worsening shortness of breath often present again to the Emergency Department (ED). CODEHF is a process of implementing a care pathway that supports rapid diagnosis and treatment, supplemented with prospective risk stratification to identify whether patients should be admitted or can be safely discharged home with early cardiology follow-up. At four Saint Luke’s Hospitals, this was associated with a 36% increase in discharges from the ED, a 48% reduction in ‘unnecessary admissions’, and a 48-minute shorter stay in the ED. The KC QVIC is helping sites customize the intervention, implement the pathway, educate team members on its use, trouble-shoot challenges in its integration into care, and help elevate its safety and impact. 

Managed Services Network (MSN): The Mid-America Regional Council (MARC) has built a program to engage and coordinate community based organizations (CBOs) in providing a coordinated network of services to address the social determinants of health such as food insecurity, transportation needs, medical access, etc. The KC QVIC is helping develop a process of identifying patients likely to benefit from MSN services, implement the screening process, develop an efficient pathway for MSN referral, and evaluate the impact of intervention on care. 

Coordination with Payer-led Disease Management Programs: Most commercial payers have disease management programs to help support their members. The KC QVIC is working to help develop an inventory and referral path to help coordinate access to these programs.


  • Health Insurers:
    • Aetna
    • Blue Cross and Blue Shield of Kansas City
    • Humana
    • United Healthcare
  • Hospitals:
    • Advent Health
    • Cass Regional
    • North Kansas City Hospitals
    • Olathe Health
    • Overland Park Regional
    • Providence
    • Saint Luke’s Health System
    • Truman Medical Centers
    • University of Kansas Hospital
  • Mid America Regional Council (MARC)
  • Researchers
    • Saint Luke’s Mid America Heart Institute (MAHI)
    • University of Missouri – Kansas City (UMKC)

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