“Efforts to improve postdischarge outcomes for patients with heart failure have focused on care coordination through provision of telephone contacts and clinic visits, with mixed results. Prior literature indicates that postdischarge phone calls alone do not reduce emergency department revisits or hospital readmissions. There is mixed evidence that more intensive interventions, such as structured home and clinic follow-up visits, are effective, with more recent trials showing lower efficacy, possibly due to better in-hospital care. The Mighty-Heart trial adds to this literature by demonstrating that a high-intensity intervention offering home visits by paramedics and telehealth visits with an emergency medicine physician did not improve patient outcomes. [..]
Perhaps it is time to reconsider the problem and the solutions. Should we look upstream for future interventions, targeting appropriateness of discharge decisions, quality of inpatient heart failure care, and management of other chronic conditions during heart failure hospitalizations? Should high-intensity programs, such as the MIH [mobile integrated health] programs studied in the Mighty-Heart trial, be targeted toward higher-risk patients and be managed by experts in heart failure? Or, given that most patients with heart failure face both frailty and multimorbidity, should transitional interventions focus less on readmissions and more on patient priorities and be managed by geriatricians and primary care clinicians?”
Full editor’s note, TS Anderson and D Grady, JAMA Internal Medicine, 2025.9.15