MedicineEducation

Harriet Sono

2026.1.15Professional Case Management

DOI: 10.1097/ncm.0000000000000843

tlooto Summary

It is suggested that postdischarge follow-up calls and patient education alone may not be sufficient to reduce readmissions, and case management should focus on more comprehensive interventions, improved care coordination, and exploring alternative models of care, such as community-based or integrated care teams.

Abstract

PURPOSE OF STUDY This study aimed to assess the effectiveness of postdischarge follow-up calls and patient education in reducing 30-day readmission rates for congestive heart failure (CHF) patients aged 60 and older. CHF is a common and debilitating condition, especially in older adults, leading to poor health outcomes and rising health care costs. As the number of CHF patients is projected to exceed 8 million by 2030, managing high readmission rates remains a major challenge in health care.

PRIMARY PRACTICE SETTINGS The study took place in the cardiovascular unit of a hospital, focusing on patients who had recently been discharged following a CHF-related hospitalization.

METHODOLOGY AND SAMPLE A quantitative design was used, with 12 CHF patients participating in the study. Participants received educational materials about managing their health, adhering to medications, and scheduling follow-up appointments. They also received follow-up calls to monitor progress and offer support. Data were collected before and after the intervention, and statistical analyses were performed to compare 30-day readmission rates between the two groups.

RESULTS The results indicated no statistically significant difference in readmission rates between the pre- and postintervention groups (p = .138). This lack of significance may be attributed to the small sample size or the limited effectiveness of the intervention.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE The study suggests that postdischarge follow-up calls and patient education alone may not be sufficient to reduce readmissions. Case management should focus on more comprehensive interventions, improved care coordination, and exploring alternative models of care, such as community-based or integrated care teams. Further research is needed to identify more effective strategies to address CHF readmissions.

Citation format

SONO, Harriet. Reducing readmission rates in heart failure patients aged 60 and older through education and follow-up calls. Professional Case Management, 2026, 31 2(2): 57–68.