This study is trying to improve the hospital-to-home transition for people with heart failure who receive home care services. The study will test an intervention called I-TRANSFER-HF, which differs from usual care by combining early home health nurse visits and outpatient medical appointments. The study is interested in two questions: 1. Is I-TRANSFER-HF better than usual care at preventing heart failure patients from returning to the hospital within 30 days? 2. Are there parts of I-TRANSFER-HF that are easy or hard to implement in the real world? The researchers will answer these questions by testing the intervention among pairs of hospitals and home health agencies across the country. During the study, the hospital-agency pairs will be asked to implement I-TRANSFER-HF. The researchers will then compare the results from before and after I-TRANSFER-HF was adopted. They will also interview people from these hospitals and agencies to see how I-TRANSFER-HF is being implemented under real-world conditions.
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All-cause 30-day hospital readmission
Timeframe: 30 days following post-Index HF Hospitalization
Number of Eligible patients
Timeframe: 12 months
Number of Eligible Patients Who Received Protocol Components
Timeframe: 12 months
Modality of outpatient follow-up
Timeframe: 12 months
Timeliness of Post-Hospital Discharge Home Health Nursing Evaluation
Timeframe: 12 months
Timeliness of Post-Hospital Outpatient Follow-Up
Timeframe: 12 months
Feasibility of implementing I-TRANSFER-HF (Qualitative Interviews)
Timeframe: 30 days after intervention (year of intervention)
Feasibility of implementing I-TRANSFER-HF (Surveys)
Timeframe: 30 days after intervention (year of intervention)