The key to the program is an in-hospital clinic staffed by nurse practitioners who reviews post-discharge instructions with patients. it addresses such issues as some patients’ difficulty getting to drugstores and matters connected with low-income and educational status.

Hospitals & Health Networks reports on the UVA program:

“In an effort to reduce readmissions, a patient’s entire care team — doctors, nurses, floor managers, case workers, discharge managers, pharmacists, residents and social workers — visits on the morning of discharge, as on other mornings of the patient’s stay, in a program they call ‘Rounding with Heart.”’

“UVA strives to provide a ‘very clean’ discharge summary that patients can understand easily, with no ambiguities. The discharge nurse reviews discharge instructions with the patient in the presence of a family member.”

“As part of the H2H program, patients are scheduled to visit UVA’s H2H {Heart to Heart} clinic between four and seven days post-discharge. Patients come in for an hour-long appointment to the clinic run by two full-time nurse practitioners who specialize in heart failure. The nurse practitioners also consult on cases with dietitians, genetic counselors, physical and occupational therapists, and social workers.”

“The program was found to reduce mortality at 30 days to 1.8 percent, down from 12.9 percent, and at one year to 15.5 percent, down from 25.6 percent. The average cost of care over the year after was $45,617 for the H2H patients and $101,022 for those not in the program.”