Home Health Transitional Care Interventions (TCI) to Reduce Rehospitalization in Geriatric Patients with Heart Failure

This evidence-based project evaluates the evidence that high-intensity transitional care interventions at home are effective at preventing re-hospitalization, reducing mortality and improving quality of life in geriatric patients with heart failure. The project recommends consistent implementation, at home, of an interdisciplinary team, use of a standardized tool to assess re-hospitalization risk and regular use of the Teach Back method for patient and caregiver education (AHRQ, 2015). These strategies should be part of the standard outpatient intervention.