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Background: High hospital readmission rates contribute to rising health care costs and lower quality of care, particularly in cardiac patients. Transitional care programs that expedite post-discharge visits have the potential to improve this problem. This study examined the effectiveness of one such program, Bridging the Discharge Gap Effectively (BRIDGE), a single-visit, nurse-practitioner-led, cardiac transitional care program. Methods: We retrospectively abstracted demographics, comorbidities, and 6-month outcome data on all patients referred to BRIDGE from 2008-2013. Demographics and outcomes were compared between BRIDGE attenders and non-attenders. A secondary analysis of timing and reasons for readmissions was also conducted among Acute Coronary Syndrome (ACS) and Heart Failure (HF) patients. Results: Of 2,367 patients referred, 1,716 (72.5%) attended BRIDGE. Few demographic differences were seen between BRIDGE attenders and non-attenders. BRIDGE appointments were scheduled much sooner than appointments with other health care providers. ACS attendees had significantly lower 30-, 60-, and 90-day readmission rates than non-attendees, but there were no differences in readmission rates for both HF and Atrial Fibrillation (AF) patients. Of ACS and HF patients who were readmitted within 30 days, greater than 50% were readmitted at 0-14 days post-discharge. Conclusions: The BRIDGE clinic is an easily transportable model for transitional care and has proven effective in decreasing readmissions in the ACS population. Further research is needed to develop successful preventive strategies for the vulnerable populations identified through this and other transitional care models.

Transitional Care to Reduce Cardiac Readmissions: 5-Year Results from the BRIDGE Clinic