Research Article| Volume 27, ISSUE 11, P1185-1194, November 2021

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An Interprofessional Collaborative Practice Can Reduce Heart Failure Hospital Readmissions and Costs in an Underserved Population

      Highlights and Brief Lay Summary

      • An interprofessional collaborative practice can be a successful model in caring for underserved patients with heart failure.
      • Addressing social determinants of health can lead to improved heart failure outcomes.
      • Decreasing hospital readmissions among underserved patients with heart failure can significantly decrease costs for hospitals.
      The goal of the Heart Failure Transitional Care Services for Adults clinic is to increase access to care for underserved patients admitted to our hospital with a diagnosis of heart failure. By providing a medical home for this underserved population and addressing social determinants of health (basic needs assessed, food insecurity, access to medications, housing, safety, transportation, social support, and financial assessment), we aim to improve the overall physical and mental health outcomes of patients and decrease hospital costs.



      Heart failure is a leading cause of hospitalization among adults in the United States. Nurse-led interprofessional clinics have been shown to improve heart failure outcomes in patients with heart failure, specifically decreasing readmission rates. Yet, there is little information on the impact of nurse-led interprofessional collaborative practice within an underserved population with heart failure. Thus, the purpose of this study was to compare the differences in readmission days and cost in patients followed by an interprofessional collaborative practice clinic (both engaged and not engaged) and those who did not establish care with the clinic.

      Methods and Results

      Demographic, clinical, and readmission data were compared among patients with heart failure (59% African American; 72% male; mean age, 49 years) stratified into 3 groups: engaged patients (n = 170), not-engaged patients (n = 103), and not-established patients (n = 111) who had an initial appointment to clinic but did not establish care. Patients with 6 months of data before and after the scheduled clinic visit were included in the study. Differences in baseline characteristics, frequency and length of hospital admissions, and costs were analyzed using analysis of variance, Wilcoxon matched-pairs testing, multivariate analysis of variance, logistic regression, and financial analytics. Overall, the number of inpatient hospital days decreased in the engaged group compared with those in the not-engaged and not-established groups (P < .001). The total cost savings were significantly greater in the engaged group ($1,987,379) (P < .001).


      The findings of this study may steer health care providers to incorporate interprofessional collaborative practice into heart failure management with a particular focus on underserved populations.

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