Barriers to Timely Follow-up for Heart Failure Hospitalization

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Researchers examine patient barriers when receiving follow-up for heart failure hospitalization.

According to guidelines, patients hospitalized with heart failure should have an ambulatory follow-up visit within 1 to 2 weeks of discharge. This recommendation is not only best practice, but it is critical. Dire statistics plague heart failure patients, including an average 25% readmission rate within 30 days of discharge and a 33% fatality rate in the year following hospitalization.1

A study published in 2023 revealed that timely follow-up simply isn’t happening for most patients in underserved populations. When analyzing the Medicaid data of 9859 patients with diabetes and heart failure in Alabama, researchers found that about 31% of patients completed their postdischarge visit late (within 60 days), and almost 27% had no visit. In addition, the vast majority (over 70%) followed up with their primary care doctor, while only 12% saw a cardiologist.2

Social barriers, such as lack of transportation and limited access to medical care, increase heart failure complications and readmission rates.3 By understanding the impact of these social determinants of health, progress can be seen for reducing heart failure, a disease impacting over 6.5 million Americans, leading to over 1.9 million hospitalizations, and costing the country at least $31 billion each year.4 Here’s why so many patients never make it to their postdischarge appointment and how successful programs are testing blueprints to reverse the trend.

What Are the Social Determinants of Health?

The social determinants of health are the conditions that impact health care outcomes beyond an individual’s clinical risk factors. These encompass 5 domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context.

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Social determinants of health may also be viewed as the “conditions in which people are born, live, learn, work, play, worship, and age.”3

Intentionally reaching patients, even using existing resources, can make all the difference in overcoming barriers and raising short-term monitoring and survival rates.

There are many well-established connections between the social influences of health. Data published in 2021 by the World Health Organization estimated that 30% to 55% of health outcomes are directly related to social determinants of health.3 The American Heart Association has also acknowledged the impact of social factors, like environment, lifestyle, and stress, on chronic disease management, calling for individual and neighborhood-wide initiatives. Patients require more support with both navigating the health care system and learning to care for their chronic conditions at home.

As researchers narrow the focus to heart failure, more opportunities for progress arise. For example, poverty increases toxic stress associated with physical consequences like high blood pressure and inflammation.3 Unsafe neighborhoods limit outdoor exercise, and substandard education reduces health literacy and the ability to manage chronic conditions. Additionally, patients with a network of support are more likely to have caregivers, help with transportation, and lower levels of anxiety and depression.3 While there are no easy fixes for these complex issues, better data enables the design of value-based care models for holistic patient care.

Challenges in Quantifying the Problem

Despite the value of social data, it is not always easy to measure. For instance, some studies rely on whether the patient is married or has children to determine their level of social support. While this information can be readily sourced from electronic medical records (EMR), it is not necessarily validated or guaranteed to paint an accurate picture. Current EMRs are not necessarily designed to capture the many social determinants of health that exist. Therefore, collecting less concrete information, like a patient’s level of spirituality, remains a challenge.3

In addition, patients are multifaceted and don’t always fit neatly into a box based on their social determinants of health. Characteristics overlap and interact, such as race, sex, and income. While associations with outcomes like heart failure follow-up are helpful, they tend to fall short of producing a comprehensive patient profile. Fortunately, there’s no harm in providing interventions that help patients schedule appointments, get easier access to care, and learn how to manage their health. Taking a more proactive and hands-on approach offers potential payoffs for heart failure patients from all walks of life.

Effective Interventions Worth Repeating

A study on 261 heart failure patients reviewed how interventions can produce significantly higher rates of postdischarge follow-up. Those in the intervention group had a 40% referral rate and 24% completion of a cardiology visit within 7 days of discharge, compared to just 12% referral rate and 10% completed visit in those receiving standard care. By 14 days postdischarge, 55% of the intervention group had a scheduled appointment versus 31% of nonintervention patients. Not only was the intervention successful in boosting timely postdischarge visits, but it was also associated with a 41% lower rate of emergency department visits, all-cause hospitalizations, and deaths 30 days after discharge.1

To achieve these promising results, researchers implemented a transitional care pathway at the Phoenix Veteran’s Affairs Medical Center.1 They asked the hospitalist team to refer all patients admitted with a primary diagnosis of heart failure within 7 to 14 days postdischarge. In the triage process, a heart failure clinic consult was created for these patients, prompting a meeting with the cardiology nurse before discharge. During this visit, the nurse instructed the patient on self-care, providing them with a blood pressure cuff and a scale. The nurse also ordered laboratory tests and scheduled a postdischarge heart failure clinic appointment. Patients were given the clinic’s contact information and daytime access to the nurse by phone to answer questions, refill medications, facilitate clinic scheduling, and address any concerns once they returned home. The clinic had 12 spots each week where patients could meet with a newly hired cardiologist or 1 of 3 preexisting nurse practitioners. In addition, telehealth monitoring and Veterans Health Administration home nursing services were available.

This study is just one example of how a targeted intervention can improve outcomes for heart failure patients. Intentionally reaching patients, even using existing resources, can make all the difference in overcoming barriers and raising short-term monitoring and survival rates. Providing a nurse liaison, patient resources, and increasing clinic capacity greatly impacted how many patients ended up with timely follow-ups. Continued research on the long-term effects of this type of intervention can help quantify the value of heart failure interventions, both in health care dollars and quality of life measures.

Can Specialists Be All Things to All People?

Ultimately, medical care cannot be effective without reaching the patients that need it. No matter the specialist’s skill set or the advancements in medical technology, sometimes there is no substitute for supportive nursing staff and a clinic with the capacity to see more patients. Heart failure statistics show that there is still much work needed to keep patients from falling through pivotal gaps in care. Robust health care networks must utilize social workers, nursing staff, and community resources to ensure the welfare of their patients after they leave the hospital.

Specifically, vulnerable heart failure patients must be reached in the early days postdischarge to reduce readmissions and improve survival rates.1 From redesigning EMRs to include the social determinants of health to implementing comprehensive outreach programs initiated before discharge, efforts along the health care continuum can save future burdens to the medical system and the individual patients it serves. If “an ounce of prevention is worth a pound of cure,” initiatives for better follow-up care in postdischarge heart failure patients is well worth the initial investment.


  1. Dev S, Fawcett JP, Ahmad S, Wu W-C, Schwenke D. Implementation of early follow-up care after heart failure hospitalization. AJMC. 2021;27.
  2. Khodneva Y, Levitan EB, Arora P, Presley CA, Oparil S, Cherrington AL. Disparities in post-discharge ambulatory care follow‐up among Medicaid beneficiaries with diabetes, hospitalized for heart failure. JAHA. Published online June 7, 2023.
  3. Enard KR, Coleman AM, Yakubu RA, Butcher BC, Tao D, Hauptman PJ. Influence of social determinants of health on heart failure outcomes: a systematic review. JAHA. Published online January 25, 2023.