Improved care of elderly patients with heart failure has led to shorter hospital stays and lower rates of death while in the hospital. Unfortunately, after leaving the hospital, many of these patients are at risk of being admitted to a nursing home, are frequently re-admitted to the hospital, or die in the month following hospital discharge. Working with a multidisciplinary team, UCSF Medical Center has been able to care for more patients in their homes, prevent hospital readmissions and provide palliative care for those with late-stage heart failure.
Heart failure affects about 5 million Americans, and is the leading cause of 30-day hospital readmissions among older patients. It is a chronic, progressive disease in which the heart is unable to pump enough blood to the rest of the body, causing fatigue, shortness of breath and swelling in the feet and legs. Patients often take multiple medications to manage their illness, must restrict their salt intake, and need to weigh themselves daily to detect whether they are retaining excess fluid, which can back up into their lungs. Yet despite the complexity of the disease, some studies have estimated that up to half of heart failure readmissions are potentially preventable.
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