Outpatient Heart Failure Programs Up the Game in Cardiac Rehabilitation

Intensive outpatient programs designed to help patients discharged from the hospital after acute heart failure events successfully reduced early hospital readmission rates through frequent follow-ups, targeted interventions, and nurse-led education, according to data presented at the 2026 Annual Meeting of the American Association of Heart Failure Nurses (AAHFN 2026) in San Diego, California. 

Heart failure has become a major public health concern and a leading cause of hospitalization for adults across the United States. Readmissions within 30 days affect approximately one-quarter of patients with heart failure, leading to high healthcare costs and unfavorable outcomes [Suleman MT et al. Cureus 2025;17:e95741]. While underlying comorbidities contribute to early readmissions, challenging medication regimens and a lack of close clinical monitoring are also major drivers of 30-day readmissions in this population. In recent years, intensive programs featuring proactive patient education, medication reconciliation, and seamless transitional care have been created across the country to address these barriers, with the aim to improve prognosis for patients with heart failure. 

The heart failure program established at the Novant Health Heart and Vascular Institute in Winston-Salem, North Carolina was designed to optimize heart failure management for patients who were recently discharged from the hospital after acute heart failure events, while maintaining patient independence and enhancing quality of life. The 8-week outpatient program, known as the Heart Failure Bootcamp, targets vulnerable patients who are at increased risk for early readmission and poor clinical outcomes. The program features six follow-up visits with a nurse practitioner or pharmacist, who helps with medication titration and optimization, as well as a series of educational sessions focused on symptom management, diet and activity recommendations, medication adherence, and social support. Participants are assigned weekly homework to review specific sections and return with questions for providers, reinforcing active learning. 

“One of the program’s primary goals is to empower patients with the knowledge and skills necessary to manage their condition confidently and independently, reducing the likelihood of readmission and improving quality of life,” the authors noted. The bootcamp has, so far, enrolled 59 patients, with a graduation rate of 71%. An analysis presented at AAHFN 2026 showed that the intervention increased adherence to guideline-directed medical therapies, with 85% of participants achieving maximally tolerated doses before the completion of the bootcamp. The intervention also reduced 30-day and 6-month readmission rates through care coordination and targeted follow-up. 

Presenting author Derrick Andrews, RN, MBA, manager of the heart failure program at Novant Health, stressed that nurse-led education has been instrumental in empowering patients and their families to manage heart failure at home. While the pilot program has, so far, enlisted only one nurse practitioner and one pharmacist who see patients for check-in appointments every other week, the hope is to expand the program to include multiple providers and potentially additional clinics. “The more frequent these [medical] checkpoints, the more likely that readmission rates will decrease,” Andrews said, noting that delivering structured, goal-driven interventions can improve short- and long-term care for patients with heart failure.  

The success of a heart failure management clinic established at a quaternary medical center in Milwaukee, Wisconsin in reducing readmission rates further proved that close clinical monitoring after hospital discharge and multidisciplinary care coordination can improve outcomes for patients with heart failure. The heart failure program at Aurora St. Luke’s Medical Center, established in March 2025, includes an interdisciplinary team led by a nurse practitioner, supported by inpatient and outpatient nurse navigators, pharmacists, and medical assistants. After inpatient nurses initiate the referral during hospitalization, patients with heart failure are seen in clinic for a follow-up appointment within 7 days of hospital discharge. The targeted follow-up visits enable providers to assess clinical status, optimize treatment regimens, and escalate care, as needed. This early review facilitates timely intervention, continuity of care, and patient self-management, which may prevent additional acute events. 

The data presented at AAHFN 2026 showed that patients enrolled in the early follow-up program at Aurora St. Luke’s Medical Center experienced fewer early readmissions for heart failure (0.61%) compared to those without early follow-up visits (1.09%). The 30-day readmission rates were also lower than predicted for this population. 

As of April 2026, the clinic has provided care to 479 patients, including 354 new patient visits and 506 follow-up encounters, suggesting that referral volumes and engagement in ongoing heart failure management continue to grow. While the complexity of care and socioeconomic barriers may limit the applicability of the intensive intervention, the authors noted that this model has the potential to bridge the gaps between acute hospitalization and outpatient management, ultimately improving heart failure care.