HAP Resource Center

Case Study: UPMC Pinnacle 2019 HAP Achievement Award

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Awarded for:  Heart Failure Hospitalist Team:  An Example of Interdisciplinary Excellence

Excellence in Care

Large Organizations

Clinical team at UPMC PinnacleThe goal:  To improve continuity of care for heart failure patients and reduce avoidable readmissions.

An interdisciplinary heart failure team created a heart failure hospitalist service to support an environment of patient-centered care across the continuum.

The heart failure hospitalist team:

  • Provides evaluation and management and optimizes patients’ medications
  • Educates patients and families so they can understand and follow treatment plans
  • Introduces the concepts of palliative and hospice care
  • Coordinates care with outpatient providers
  • Supports patients’ self-management of outpatient care through visits to review action plans, goals of care, medication reconciliation, and education

The team also implemented innovative techniques such as:

  • The use of paramedics to carry out intravenous diuretic protocols in patients’ homes
  • Virtual doctors’ visits via telemedicine
  • Technology to monitor patients’ conditions in order to prevent readmissions

Results:  The program resulted in:

  • Decreased length of stay for heart failure patients
  • A nearly 50-percent reduction (to 9%) in the 30-day all-cause readmission rate compared to the readmission rate for heart failure patients not supported by the heart failure hospital team and national readmission rate averages
  • Reduced costs



Topics: Public Health, Quality Initiatives

Revision Date: 9/1/2019

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