Header Heart Failure Patients

Helping Heart Failure Patients Avoid Hospitalization in Indiana

More than 5.7 million American adults are living with heart failure. The Department of Health and Human Services (HHS) projects that the prevalence of heart failure will increase 46 percent from 2012 to 2030, resulting in 8 million adults living with the chronic condition.1

Congestive heart failure is one of the top three reasons for hospital readmissions in northeast Indiana, according to the local Care Coordination Community there. Dupont Hospital in Fort Wayne collaborated on a congestive heart failure pilot with a skilled nursing facility (SNF) and a home health agency (HHA).

The pilot project was designed for patients with a diagnosis of heart failure who are transitioning from the hospital to either a rehabilitation facility or going home with home health services.

“The pilot was created to improve what we were doing for patients and to help them be more successful after being discharged,” said Lisa Cotten, Physician Assistant.

Cotten said the project helped patients understand the resources available, learn more about their disease and find the options to help them stay out of the hospital. It also showed the collaborators where they could improve internally on processes, which raised the quality of care and outcomes not only for each of them but also for the community, she said.

“Healthcare today is splintered, no one is communicating across the continuum and we still have far too many gaps patients get lost in,” said Cotten. “We really worked together as a team to help patients with heart failure do it differently this time to stay out of the hospital.”

Finding a Pathway

The pilot developed by Lisa Cotten, PA-C, and Teresa Delellis, Pharm D, BCPS, BCGP, from Dupont Hospital lays out a clear pathway for patients with heart failure to transition across the continuum, increasing their chance of staying out of the hospital each step of the way. Rehabilitation and Home Care representatives met with patients prior to discharge and educated the patient about their services. For the first time, patients were able to learn about those resources from a person, not by picking from a list.

All the collaborators educated patients on their disease and how to better manage it at home. The patients also had a follow-up appointment scheduled with their cardiologist or the heart failure clinic prior to being discharged from the hospital. A pharmacist also followed up with the patients over the phone or in person.

If the patient went to a rehabilitation facility, then they were assigned home health care after their stay was complete. If the patient opted to go home from the hospital with home care services and became ill again, then they were routed to the rehabilitation facility rather than the Emergency Department (if clinically appropriate).

“The methods we implemented with this pilot were a great reminder of the purpose of discharge planning and that we need to consider disease-specific concepts when assessing for discharge needs,” said Marcia Kessler, a registered nurse and team specialist for Dupont Hospital. “The congestive heart failure assessment we used in this pilot went beyond the standard questions included in our discharge assessment tool. Everyone who interacted with the patient was speaking the same language.”


The rate of patients being readmitted into the hospital with heart failure was lowered from 18.2 percent to 6.1 percent. During the six-month pilot project, 155 high-risk patients diagnosed with heart failure were guided through the congestive heart failure pathway and only eight were readmitted to the hospital. Qsource estimates that this project prevented 20 patients from being readmitted and saved the Medicare health system approximately $175,260.2

Looking Ahead

The national readmissions rate averaged 25 percent in 2017, while the rate in Indiana averaged almost 24 percent. Considerably lower than the nation and state averages, Dupont Hospital has an average overall readmission rate of 19 percent.3Following the success of the pilot project, the hospital is planning a similar one to reduce readmissions for patients with chronic obstructive pulmonary disease (COPD).

“We got back to patient-centered medicine and old school communication and education to better set the patient up for success. We learned a lot and we now can adjust and tackle the next phase to continue doing better for our patients,” said Cotten. “Together as a team, we were able to create a better process across the continuum. It was a privilege to work with Dupont Hospital, who continues to set the bar for the geriatric population in Indiana. We are looking forward to continuing this partnership to impact patient care.”

Qsource would like to thank the participants – Dupont Hospital, Kingston Healthcare and Great Lakes Home Health Agency – for their contributions to this project and making healthcare better for the older adults of Indiana.



  1. NIHB, Health and Human Services
  2. Calculation based on the average CY2017 Indiana Hospital Medicare heart failure reimbursement rate
  3. Medicare part A claims data