The Fremont Medical Center is leading efforts in the community to reduce readmission rates for patients with CHF. This improves quality of life for patients, reduces the risk of complications, and minimizes avoidable health care costs.

The Patient Care Coordinators (PCCs) implemented evidence-based interventions by leveraging data to identify high-risk patients. Once these patients are stable for discharge, PCCs ensure the cardiac heart failure stop light is included in the discharge instructions. PCCs also send Home Health referrals for qualified CHF patients and include a multidisciplinary note with contact information for appropriate home health hub.

PCCs send referrals to Complex Chronic Conditions Case Managers and coordinate with hospitalist. The results are discussed with the interdisciplinary team and proactively validate that care coordination processes are effectively implemented for patients with a primary CHF diagnosis.