In 2008, the University of California, San Francisco (UCSF) Medical Center embarked on a grant-funded program to reduce hospital readmissions for elderly patients with heart failure. With support from medical center leaders and a multidisciplinary team, program coordinators provide enhanced patient education and follow-up care connections to promote the patient’s successful transition to home or to skilled nursing care. Over two years, rates of all-cause heart failure readmissions in the target population declined by 46 percent within 30 days of hospital discharge and by 35 percent within 90 days. With internal funding, the program is being sustained and expanded to younger patients. The medical center applies learning from the program to support the goal of reducing all readmissions as part of a performance incentive program for public hospitals. Program staff highlight collaboration and communication as key factors to the program’s success.
Note: These case studies were based on publicly available information and self-reported data provided by the case study institutions. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case study series is not an endorsement by the Fund for receipt of health care from the institution.