PCPs Key to Heart Failure Care After Discharge

Lori Youmshajekian

July 05, 2023

Madeline Sterling, MD, knew something was wrong when she heard her patient's voice on the phone. The patient was breathing too fast and sounded fatigued. Like many people with heart failure, this patient had several comorbidities: diabetes, high blood pressure, and cancer, which was in remission.

The patient had been in and out of the hospital several times and was afraid of going back, but Sterling, a primary care physician, advised her that it was the safe thing to do.

During the woman's stay, the inpatient cardiology team called Sterling to provide status updates and ask for input. When the patient was discharged, Sterling received information on what medicines had been changed and scheduled follow-up care within 10 days. Sterling, who'd cared for the woman for many years, called her family, her home health aide, and another caregiver to discuss the plan.

"When you know these patients really well, it's helpful," Sterling, an assistant professor of medicine at Weill Cornell Medicine in New York City, said. Primary care clinicians have "an appreciation for how all these conditions fit together, how the medicines fit together, and how to put that patient's priorities at the front of the equation."

Follow-up care within 7 to 10 days after discharge, especially for patients with heart failure, can prevent hospital readmissions, research has shown. Patients' health can change rapidly following discharge: They may start retaining fluid or not know how to maintain a low-sodium diet, or they might have trouble obtaining medication. Primary care clinicians spot these early warning signs in follow-up visits.

Heart failure affects more than 6 million adults in the United States, according to the Centers for Disease Control and Prevention. The condition is a common cause of hospital readmissions within 30 days of discharge, according to research published by the American Heart Association.

Patients with heart failure are particularly challenging to care for because of comorbidities.

Dr Noah Moss

"They're a very, very sick group of patients that are very difficult to manage," said Noah Moss, MD, an advanced heart failure and transplant cardiologist at Mount Sinai Hospital in New York City.

But patients do not always receive the follow-up care they need, some studies have found.

Right Drugs at the Right Time

Kelly Axsom, MD, a cardiologist at the Columbia University Medical Center and director of the centralized heart failure management program at the New York–Presbyterian Hospital System, in New York City, called the primary care clinician the "captain of the ship," ensuring that medications are reconciled and providing education about what to eat after discharge.

"It's actually pretty complicated to go from being in the hospital to being at home," Axsom said. "There are often many medication changes, there are lots of instructions that are told to you as a patient that are hard to remember."

A patient's weight might fluctuate in the days following discharge because the dose of diuretics might be too low or too high and need to be adjusted, according to Ishani Ganguli, MD, MPH, an assistant professor of medicine and a general internist in the Division of General Internal Medicine and Primary Care at Harvard Medical School and Brigham and Women's Hospital, in Boston.

Dr K. Melissa Hayes

K. Melissa Hayes, DNP, ANP-BC, CHFN, an assistant professor in the adult gerontology primary care program at the Vanderbilt University School of Nursing, in Nashville, Tennessee, recalled one patient who was given a months' worth of medications following his discharge from the hospital.

"He was given expensive medications he couldn't afford, and not any refills or how to get those medications," Hayes said.

Sometimes patients have no way to get to the pharmacy, or their pharmacy doesn't have the medication they need, or their insurance doesn't cover the drugs.

"The average patient is on at least six medications for heart failure, maybe even seven, and then that's not including all their other medications," Hayes said. "That can be a lot for people to keep up with."

Hayes talks to her patients with heart failure about what drugs they have been prescribed and what medications they require more of, and she deprescribes any that are duplicative.

Helping patients understand why they are taking each drug encourages them to stick to the regimen. Diuretics, for example, can lead to frequent urination. If patients are unable to take regular bathroom breaks, they may be tempted to stop using the medication ― a potentially catastrophic mistake.

"Often I have patients say, 'Nobody ever explained it to me that way,' " Hayes said. "Someone can have a PhD but not understand their medications."

Clinicians also can alert patients to commonly used medications that can worsen heart failure, such as diabetes drugs and over-the-counter medications such as ibuprofen.

Patients should be prescribed a combination of four recommended medications. But several studies have found that clinicians often fail to achieve the target doses for those medications. The use of guideline-directed medications reduces mortality and hospitalization rates, according to multiple clinical trials.

Eyes and Ears on the Patient

Once home, patients must stick to the right diet, weigh themselves every day, and monitor their blood pressure. But changing behaviors can be a struggle.

"Being seen quickly within a couple of days of discharge, you can catch things," said Hayes, who has edited a book on managing patients with heart failure in primary care.

Dr Marc Itskowitz

"It's an opportunity to see how they're doing at home, make sure they have their medications, make sure there's been no misunderstanding or miscommunication about what they're supposed to be doing at home," says Marc Itskowitz, MD, a primary care physician with the Allegheny Health Network in Pittsburgh, Pennsylvania.

Ideally, a record that readily integrates information from wearables ― such as blood pressure and weight ― would make it easier to spot abnormalities, Itskowtiz said. "I think we're still in the infancy of the electronic health record," he said.

Ensuring that follow-up visits are as accessible as possible for patients is also important. Telehealth makes it easier for patients after they return home from the hospital, Itskowitz said.

More Infrastructure

Another challenge of providing follow-up care for patients with heart failure is completing all the tasks a clinician must do within a 20-minute visit: an examination, education on the condition and medications, counseling on diet and exercise, coordination of medical equipment, such as a blood pressure cuff for home use, and making appointments with specialists.

"In the current system, additional support for primary care is needed so we can do all this," Sterling said.

Staff at primary care clinics should be trained to answer calls from patients when they experience changes in their weight or are worried about other potential problems. "A lot of primary care practices are bare bones," Hayes said, meaning they might not have the staff to field those calls. Educating patients as to when they should call their physician, especially after experiencing worsening symptoms, is also important.

Hayes suggests setting aside time in the schedule each week to see patients who have been recently discharged from the hospital. In the Cardiology and Vascular Clinic at Nashville General Hospital, where she spends half a day each week, Hayes requests 30 minutes to see patients who have recently been discharged from hospital.

Even when the process goes smoothly, some patients will return to the hospital because of the progressive nature of heart failure, according to Hayes. Improving care following their hospitalization can keep these people from rapidly declining.

"Most patients with heart failure want to be taking care of the grandchildren or be able to enjoy family dinners together," Axsom said. "I think anything we can do to help improve their quality of life is really important."


  • See heart failure patients early after their discharge from hospital, ideally within 7–10 days.

  • Make sure patients have access to the right medications at the right dosages and that they know why they're taking them.

  • Educate patients about the diet they should be following.

  • Have a system to monitor patients' symptoms, and let them know when they should call.

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