Helping heart failure patients transition safely from hospital to home just got easier. Our cardiovascular team has implemented four focused strategies that remove common discharge barriers, ease documentation burdens and make follow-up care more seamless — leading to fewer readmissions, smoother workflows and better support for patients during a critical window of recovery.

CHF Medication Support Program (formerly, Meds to Beds): Eliminate medication access delays at discharge

The CHF Medication Support Program, in partnership with Walgreens, removes the frustration of sending patients home with prescriptions they can’t fill. Instead of delays or uncertainty around medication access, you can discharge patients knowing essential medications are already in their hands.

The program focuses on core heart failure medications including lisinopril 10 mg, metoprolol succinate 12.5 mg, spironolactone 25 mg, losartan 50 mg and diuretics (with provider-determined dosing). Physicians and APPs retain full flexibility to add or remove medications based on individual patient needs. Each patient receives a one-time, 30-day supply with no refill option.

The heart failure coordinators and case managers evaluate each patient’s social determinants of health to identify potential medication access barriers. When obstacles are identified, simply initiate a case management consult in Epic using “CHF Medication Support Program” as the reason, and the team will handle the authorization and Walgreens coordination.

Skip the prior authorization headaches for Jardiance and Entresto

For patients requiring Jardiance or Entresto, we’ve simplified the process to prevent discharge delays and reduce your administrative burden. Simply place a case management consult in Epic for prior authorization as soon as these medications are considered. The case managers will assess eligibility and pursue necessary approvals. If authorization is denied, they will work directly with the prescriber to identify suitable alternatives, ensuring no patient leaves without an appropriate treatment plan.

7-Day Heart Failure Clinic Appointment: Built-in follow-up

The 7-Day Heart Failure Clinic Appointment has been created as a safety net to reduce the likelihood of emergency callbacks and/or readmissions by identifying issues early during the most vulnerable post-op discharge period. The purpose of the 7-Day Heart Failure Clinic is to provide a timely care option for patients who are unable to secure prompt appointments with their primary cardiologist. This service enables patients to be seen by a dedicated nurse practitioner who will optimize their treatment plan and address any critical care gaps, helping to reduce the risk of readmission. Patients seen in the 7-Day Heart Failure Clinic will return to their primary cardiologist for follow-up at their next scheduled appointment.

Our heart failure coordinators schedule these appointments in real-time at discharge, with details automatically appearing on the patient’s After Visit Summary. We’ve also added 21-day appointments for patients who need extended support during their recovery.

The Heart Failure Bridge Program: Empowering patients through education

The Heart Failure Bridge Program recognizes that informed patients are empowered patients. This comprehensive eight-session program covers essential topics including exercise and activity guidelines, nutrition fundamentals, sodium awareness, medication management, symptom recognition and the mind-body connection in heart failure management. This program is at no cost for the patient.

Each session combines education with clinical assessment, including weight monitoring, vital signs, edema evaluation, fatigue scaling, medication reconciliation and glucose checks when appropriate. To streamline enrollment, any provider or staff can enter an Ambulatory Referral to the Heart Failure Bridge Program (REF821) in Epic at discharge for eligible patients.

Moving forward together

These initiatives represent our commitment to evidence-based care that addresses the real-world challenges our heart failure patients face. By focusing on medication access, timely follow-up and patient education, we see meaningful improvements in patient outcomes and satisfaction.

For questions about these initiatives, contact Monika Gamel, Lynn Gerein or Lisa DeRosa.

The Cardiovascular Service Line team thanks you for your continued partnership and dedication to improving outcomes for our heart failure patients.