The SPIN TUH Transitional Care Model for Heart Failure Patients to improve quality of life

Abstract

Background: Heart failure is a chronic condition associated with high rates of hospital readmission, particularly during the transition from hospital to home. This vulnerable transitional period often reflects gaps in continuity of care, leading to adverse clinical outcomes, reduced quality of life, and increased healthcare resource utilization. At Thammasat University Hospital, the 90-day readmission rate among patients with heart failure remained high, highlighting the need for a structured and comprehensive transitional care system.

Objectives: This study aimed to 1) reduce the 90-day hospital readmission rate among patients with heart failure to less than 10%, 2) increase the proportion of patients receiving guideline-directed medical therapy (GDMT) to more than 85%, and 3) improve patients’ quality of life to more than 90%.

Methods: The SPIN TUH Transitional Care Model for Heart Failure Patients was developed and implemented using the Plan–Do–Study–Act (PDSA) quality improvement framework in collaboration with a multidisciplinary healthcare team. Key components included structured discharge planning using a Heart Failure Discharge Checklist, post-discharge follow-up via telemedicine and telenursing within 72 hours and 7 days after discharge, and the provision of consultation and education for patients and caregivers through a Line Official Account. Educational materials and self-monitoring booklets were provided to enhance self-care knowledge and skills. Pharmacists, dietitians, and physical therapists were actively involved in post-discharge follow-up, with telephone monitoring used for patients unable to access mobile applications. Outcomes were evaluated using Objectives and Key Results (OKRs).

Results: Following implementation of the SPIN TUH Transitional Care Model, the 90-day hospital readmission rate decreased to 6.08%. All patients (100%) received guideline-directed medical therapy. The mean quality of life score among patients with heart failure increased to 94.77%.

Conclusion: The SPIN TUH Transitional Care Model effectively enhances continuity of care during the hospital-to-home transition for patients with heart failure. The model contributes to reduced hospital readmissions, optimized adherence to guideline-directed medical therapy, improved self-management, and significantly better quality of life. This structured, multidisciplinary transitional care approach represents a sustainable framework that may be adapted to improve outcomes for patients with chronic conditions in similar healthcare settings.