A new study has identified some of the most common physiological reasons for 30-day unplanned rehospitalizations among heart failure patients — making it possible for case managers and others to develop interventions and strategies to address this problem.1

To fix a problem, one first must understand what causes it. This is why investigators looked at the root physiological factors behind heart failure patients’ rehospitalizations.

“The readmission rate was a little bit high,” says Omar Alzaghari, PhD, MSN, RN, assistant professor in the school of nursing at the University of North Carolina at Wilmington.

Alzaghari began to identify factors that could increase readmission risk. His first study looked at physiological factors, like cardiovascular disease, lab values, and the presence or absence of chronic kidney disease and other conditions.

“We found some significant factors that predicted rehospitalization,” Alzaghari says. “The main one was chronic kidney disease.”

Other factors associated with rehospitalization were the patient’s use of a continuous positive airway pressure (CPAP) machine and higher levels of the hormone B-type natriuretic peptide (BNP) — a heart failure hormone.

From a case management perspective, the study’s findings suggest hospitals take the following actions to reduce the risk of unplanned readmissions among heart failure patients:

• Make sure patients have functioning CPAP machines, if needed. “We have to make sure the patient goes home with a CPAP machine and it’s functioning,” Alzaghari says. “The patient also needs to know how to contact the company that provides the CPAP machine.”

Case managers can give patients the most current information about using a CPAP and ensure they are compliant with instructions for use. They can explain to patients that research shows that heart failure patients who use the CPAP properly are less likely to return to the hospital within 30 days.

Case managers can make sure patients follow up with their primary care providers after the initial discharge. “We like patients to follow up within five to seven business days, and we can make sure patients have a primary care doctor,” Alzaghari says.

If there are barriers to the patient following through on a doctor’s visit, case managers can identify and address these obstacles. They could involve the lack of funds, transportation, or other access barriers that case managers are skilled at resolving for patients.

• Focus on patient education. “Make sure patients understand their instructions,” Alzaghari says.

For example, case managers could use the teach-back method of delivering information to the patient and then asking the patient to explain the information to ensure he or she understands everything, he explains.

“I might say, ‘Tell me how often you will weigh yourself. Tell me what kind of diet you will be using at home,’” he says.

• Check medications. Hospital case managers also can help reduce readmission rates by making sure patients have the correct medication at discharge and will have access to medications post-discharge, Alzaghari says.

“Maybe we could provide the patient with medication under an indigent fund, or give the patient one or two weeks or a month supply of medication and then refer the patient to a community program,” he adds. “There also are some medication assistance programs — some run by the government and others privately run, so there are different ways you can help patients.”

• Reinforce daily behavioral changes. “We emphasize that patients have to weigh themselves every day,” Alzaghari says.

Home health staff could visit the patient’s home post-discharge and catch any problems early on, communicating the issues with the primary care doctor and assisting with an intervention, he notes.

“If patients are not following the right diet, they are putting pressure on the heart and the release of BNP is increased, indicating the heart’s function is getting worse,” he explains. “When the heart is struggling for oxygen, it needs help, and the patient gets fluid build-up in the body.”

When healthcare providers discover this problem early, they can intervene and give the patient more medication to help reduce the fluid build-up, he adds.

• Create continuum of care with community providers. Heart failure patients with kidney disease need to be very compliant with their medication regimens, and should follow up with nephrology or primary care physicians. Hospital case managers can help by making sure these provider appointments are scheduled and by calling to check whether the patient showed up to the appointments.

In some cases, case managers might have to find primary care doctors for patients before discharge. They also might need to set up a medication assistance program and connect patients with the health department, if needed, Alzaghari says.

“Before discharge, we have a new model that helps with follow-up: A nurse with a case management background makes sure the patient is doing OK and has transportation,” he says.

“This is becoming important because we can set up patients with a doctor’s appointment — but if they don’t have access to transportation to that doctor, it won’t help them,” he adds.


  1. Alzaghari O, Wallace DC. The impact of physiological factors on 30-day unplanned rehospitalization in adults with heart failure. J Comm Health Nurs. 2019;36(1):31-41.