Transiciones de cuidados entre insuficiencia cardiaca aguda y crónica: pasos críticos en el diseño de un modelo de atención multidisciplinaria para la prevención de la hospitalización recurrente

Translated title of the contribution: Transitions of Care Between Acute and Chronic Heart Failure: Critical Steps in the Design of a Multidisciplinary Care Model for the Prevention of Rehospitalization

Josep Comín-Colet, Cristina Enjuanes, Josep Lupón, Miguel Cainzos Achirica, Neus Badosa, José María Verdú

Research output: Contribution to journalShort surveypeer-review

41 Scopus citations

Abstract

Despite advances in the treatment of heart failure, mortality, the number of readmissions, and their associated health care costs are very high. Heart failure care models inspired by the chronic care model, also known as heart failure programs or heart failure units, have shown clinical benefits in high-risk patients. However, while traditional heart failure units have focused on patients detected in the outpatient phase, the increasing pressure from hospital admissions is shifting the focus of interest toward multidisciplinary programs that concentrate on transitions of care, particularly between the acute phase and the postdischarge phase. These new integrated care models for heart failure revolve around interventions at the time of transitions of care. They are multidisciplinary and patient-centered, designed to ensure continuity of care, and have been demonstrated to reduce potentially avoidable hospital admissions. Key components of these models are early intervention during the inpatient phase, discharge planning, early postdischarge review and structured follow-up, advanced transition planning, and the involvement of physicians and nurses specialized in heart failure. It is hoped that such models will be progressively implemented across the country.

Translated title of the contributionTransitions of Care Between Acute and Chronic Heart Failure: Critical Steps in the Design of a Multidisciplinary Care Model for the Prevention of Rehospitalization
Original languageSpanish
Pages (from-to)951-961
Number of pages11
JournalRevista Espanola de Cardiologia
Volume69
Issue number10
DOIs
StatePublished - Oct 1 2016

Keywords

  • Heart failure units
  • Hospital admission
  • Integrated management
  • Transitional care

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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