(P164) IMPLEMENTATION OF A NOVEL TRANSITIONAL CARE POST DISCHARGE CLINIC FOR PATIENTS WITH HEART FAILURE

Background: In 2023, a new multi-disciplinary post discharge medical clinic (PDMC) was created with input from internal medicine, cardiology, nursing and pharmacy at St. Paul’s Hospital (SPH) in Vancouver. Our clinic followed patients with heart failure (HF) who were discharged from the Clinical Teaching Internal Medicine Unit (CTU), which serves an inner-city patient population with high comorbidity burden. Patients were followed weekly for four weeks with a focus on heart failure education and medication titration. Here, we report our initial experience with this clinic.

METHODS AND RESULTS: We conducted a retrospective case series of patients discharged from the CTU ward between May and December 2023. Patients over 18 years with a diagnosis of HF who were referred to the PDMC were included. Data on demographics, medical history, medication use, and post-discharge outcomes were analyzed using descriptive statistics to assess the effectiveness of the transitional care clinic. We included 87 patients. The median age was 76 years and 31 (36%) of patients were female. The patient population had a median of 11 medications on discharge, mean LACE index score of 13.4 and 15/87 (17%) patients had active substance use. Attendance to the PDMC was associated with a 22% lower rate in 30-day ED visits and readmissions; 16/70 (22.9%) of HF patients attending the clinic had ED visits, compared to 5/17 (29.4%) who did not attend. During the weekly clinic visits, 41% of patients required furosemide titration and 41% of patients had goal directed medical therapy (GDMT) titration. The mean number of GDMT medications on hospital discharge was 1.95 and the mean number of GDMT medications on clinic discharge was 2.33. The median wait time to the first transitional care clinic visit was 10 days and the median wait time from discharge to first HF clinic (HFC) visit was 29.5 days. Overall, 45% of patients were connected to the HFC.

Conclusion: Attendance to the PDMC resulted in higher rates of furosemide and GDMT titration and was associated with lower ED visit rate. With the current wait times for HFC, PDMC may be a method of bridging patient care during this crucial initial post-discharge period. This is also a great opportunity for ongoing collaboration between cardiologists, internists, nurses and pharmacists.