CareHub: Reducing Heart Failure Re-admissions
Care Continuum
Care Process & Redesign
National University Health System Quality Improvement
National University Health System
31 December 2016
To reduce hospital readmissions for heart failure patients. Streamlined care models are critical for addressing chronic conditions and reducing hospital utilization.
Year Submitted: 2016
Published Date: 31 December 2016
Tags: Care Process ＆ Redesign, Care Continuum, Quality Improvement, Workflow Redesign, Clinical Practice Improvement, Access To Care, Readmission Rate, Intermediate and Long Term Care ＆ Community Care, Home Care, Nursing Home Care, Day Care
About this Content
Aims
To reduce hospital readmissions for heart failure patients.
Background
High re-admission rates due to lack of coordination and timely interventions post-discharge.
Methods
Used LACE risk stratification tool; established nurse-led hotlines and multidisciplinary discharge planning teams.
Results
Readmission rates decreased; increased specialist outpatient and ED visits due to early detection but no rise in re-admissions.
Conclusion
Streamlined care models are critical for addressing chronic conditions and reducing hospital utilization.
Lessons Learnt
Consolidated care systems and early interventions improve chronic disease management outcomes.
Additional Information
Pilot study results presented for further scaling
Keywords
Heart Failure, Transitional Care, Multidisciplinary Care, Readmission Reduction
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National University Health System |
Organization(s) Involved | National Heart Centre Singapore, National University Hospital, National University of Singapore, Yong Loo Lin School of Medicine |
Platform(s) | National University Health System Quality Improvement |
Healthcare Professional Group(s) | Allied Health, Nursing, Medical |
Applicable Specialty or Discipline | Cardiology |
Project Lead(s) | Weiqin Lin |
Project Member(s) |
Connect with this contributor!
Weiqin Lin - weiqin_lin@nuhs.edu.sg
Project Attachment
13_NUHS_CareHub_Reducing_Heart_Failure_Re_admissions_combine.pdf