By Melinda Young


Heart failure patients often need transitions to outpatient clinics, where they can learn how to better maintain their health and stay on their medications.

  • The Valley Hospital of Ridgewood, NJ, offers an outpatient transitional care unit for heart failure patients that reduced 30-day all-cause readmissions from 6.25% to 2.71%.
  • Heart failure patients can improve their own health and quality of life by following a program focused on medication adherence, diet, exercise, and giving up cigarettes and illicit substances.
  • Coordination programs for heart failure patients should follow national and international heart guidelines.

Hospitals that focus on collaboration between case management and transitional care clinics for people with congestive heart failure (CHF) are finding positive outcomes in their patients’ health and 30-day readmissions.

Heart failure patients can improve their quality of life if they access the resources necessary to maintain their health, says Connie White-Williams, PhD, RN, FAAN, senior director of the Center for Nursing Excellence at the University of Alabama at Birmingham (UAB) Hospital. She also is the senior director of the heart failure transitional care clinic for adults.

“For the underserved population, navigating their self-care and being good stewards of their own health are not always easy,” she says. “You can help them understand what it takes to feel better and to live a good life. It is all about taking their medicines, eating right, not smoking, giving up [illicit] substances, and trying to exercise.”

The Valley Hospital of Ridgewood, NJ, has developed a transitional care program for patients with heart failure that successfully prevents 30-day readmissions. (See story in this issue about how the heart failure transitional care program works.) The six-year-old program, which involves a dedicated outpatient transitional care unit, started as a pilot project, explains Elvira Usinowicz, APN, supervisor of the outpatient transitional care unit at The Valley Hospital.

The CHF care coordination program was established based on national and international guidelines from heart associations, critical care nursing, nurse practitioner groups, and others. The goal is to create a care plan focused on patients’ needs during hospitalization and post-discharge, Usinowicz says. It also includes best practices in communication and supervision in the seven to 14 days after discharge, she adds.

“That’s a vulnerable period for heart patients to come back to the hospital for any cause for hospitalization,” Usinowicz says. “We teach them self-care management strategies at home to take care of their heart failure condition.”

Results of a recent outcomes study shows positive change. In 2014, the rate of all-cause readmission within 30 days for patients with heart failure was 6.25%. In 2018, the rate was 2.71%.1

“What is valuable to patients and families is recognizing heart failure symptoms, which they report to their cardiologist, or call our program,” Usinowicz says. “Patients and families find this supportive, global look at how they’re functioning in the community with their heart failure as very helpful.” It empowers patients and gives them some autonomy over controlling their symptoms, she adds.

Consider Stress, Environment

When the transitional care team educates patients about their condition, they take anxiety levels and environment into account, says Christina Haddad, BSN, RN, CHFN, unit nurse at The Valley Hospital.

“For inpatients, since they are in an acute care setting, we understand their anxiety is already high,” Haddad adds. “We provide a booklet and stress the importance of three main topics: daily weights, recognition and understanding of a heart failure zone tool, and a low-sodium diet.”

The education is basic and relies on reinforcement. The team also reaches out to family members and caregivers, recognizing their importance in achieving optimal outcomes.

The UAB Hospital’s heart failure transitional care clinic is interprofessional. The clinic can refer patients to other professionals. Hospital case managers are instrumental in referring patients to the clinic’s services, White-Williams says.

“Hospital case managers are very important. They are our referral source, and all of the hospital case managers and social workers work together in partnership with the clinic,” she says. “If they know a patient is underserved, they refer them to our clinic, and we work closely with them.”

A nurse practitioner and, sometimes, a social worker are the first people to see new patients, White-Williams says. Each patient completes a routine intake with the nurse practitioner checking their vital signs, taking a medical history, and conducting a physical. Patients receive guideline-directed therapy.

“There is a full social assessment where we assess social determinants of health,” White-Williams says. “We’ve developed our own assessment.”

The social determinants of health assessment includes these questions:

  • “‘We worried whether our food would run out before we got money to buy more.’ Was this often true, sometimes true, or never true for your household in the last 12 months?”
  • “‘The food that we bought just didn’t last, and we didn’t have money to get more.’ Was that often true, sometimes true, or never true for your household in the last 12 months?”
  • Does the patient use tobacco, alcohol, or engage in substance use?
  • Has the patient experienced abuse?
  • Does the patient struggle with safety, housing, insurance, social support, food, violence, income, job training, mental health, or non-citizenship status?

Patients are assessed for depression, anxiety, and substance abuse based on the Screening, Brief Intervention, and Referral to Treatment (SBIRT) scale, which screens for severity of substance use and identifies the appropriate level of treatment. (More information is available at: The clinic also uses the Kansas City Cardiomyopathy Questionnaire, a 23-item, self-administered instrument that assesses at patients’ physical function, symptoms, social function, self-efficacy, knowledge, and quality of life. (Find out more at:

“All patients complete a depression and anxiety [screening] every time they come to the clinic,” White-Williams says.

Help Patients Take Control

CHF is a complex syndrome that causes serious illness if patients do not have access to medications or if they stop taking their medicine because of social determinants of health. “An underserved population of patients might have to make decisions about whether they should pay their electric bill, put food on the table, or take their medications,” White-Williams says. “Food for the family will win over taking care of their health.”

Heart failure also is difficult to control because it requires patients to self-manage their diet, exercise, medicines, and routine maintenance. “If they don’t take care of themselves, they could very easily end up right back in the hospital,” White-Williams says.

The goal is to help patients meet their personal goals for health and quality of life. “Part of our assessment is asking the patient, ‘What do you want? What are your goals?’” White-Williams says. “Many of them will say, ‘I want to see my daughter get married,’ ‘I have a grandchild on the way,’ or ‘I’d like to be able to breathe so I can walk around the block.’”

Transitional care nurses are passionate about education and helping patients change their behaviors for the better, says Barbara Picewicz, RN, BSN-PCCN, unit nurse at The Valley Hospital. “It is challenging to implement behavioral change. Our patients need constant positive reinforcement.”

Education is tailored to the patient’s specific needs. For example, nurses give patients a five-question test about their sodium allowance and diet choices. The team created a nutritional cart with empty boxes and cans to show the dietary information of various food items.

“This is extremely helpful for our visual learners,” Haddad says. “Patients seem to understand when the education is interactive.”

Working with heart failure patients is rewarding, says Erika Bartsch, BSN, RN, CHFN, unit nurse with The Valley Hospital. “One of the biggest joys is to see patients really feel well after joining our program. There is a real sense of making a difference in our patients’ lives.”


  1. Usinowicz E, Ronquillo K, Matossian B, et al. Reducing readmissions for heart failure. Crit Care Nurse 2020;40:82-86.