Optimizing heart failure care transitions: the MAIC Continuum initiative across 25 spanish hospitals

Abstract Background Heart failure (HF) is a growing global challenge due to its prevalence, high readmission rates, and associated morbidity and mortality. Despite treatment advancements, gaps in care transitions from hospital to home lead to poor outcomes and indreased costs. Structured, multidisciplinary approaches are needed to ensure better continuity of care. Purpose The MAIC Continuum initiative aimed to address these gaps with tailored hospital action plans. It hypothesized that standardizing discharge processes, implementing early post-discharge follow-up, enhancing team collaboration, and empowering patients would improve outcomes, reduced readmissions, and promote self-management. Methods The program was conducted in 25 Spanish hospitals, covering aproximately 6,5 million inhabitants, in three phases: Needs Assessment: A multidisciplinary advisory committee reviewed literature and conducted expert interviews to identify gaps in HF healthcare. Tools, including self-diagnostic questionnaires and discharge frameworks, were developed to support hospitals. Action Plan Development: Hospitals assessed practices and designed action plans alongside Primary Care teams in public centers to improve discharge planning, risk stratification, and follow-up care. Implementation and Monitoring: Hospitals implemented action plans over a 12-month period, tracking six key indicators: early contact within 48 hours post-discharge, a primary care visit within one week, a HF specialist consultation within three weeks, 30-day emergency visits, readmissions, and mortality as outcome indicators. The progress was monitored, and strategies were adjusted as needed. Results The program revealed recurrent needs across hospitals, including limited use of formal indicators for process times, quality of care, and patient experience; reduced discharge planning with a lack of standardized procedures; inconsistent risk identification during care transitions; and insufficient involvement of key specialties, such as pharmacy, nursing, and psychology. Many hospitals also lacked specific programs or protocols for discharge transitions. As a result of implementing an integrated care model, the first centers completing 12 months of action plan implementation have reported significant increase in early contact rates within 48 hours post-discharge, primary care visits within one week, and specialist consultations within three weeks. Additionally, the program has reduced the rates of 30-day emergency visits, readmissions, and mortality as key outcome indicators. Conclusions The MAIC Continuum initiative addressed critical gaps through tailored interventions, improving discharge planning, patient education, and multidisciplinary coordination. While early improvements in continuity of care and outcomes are promising, data collection is ongoing to assess the project's full impact. These findings will guide future efforts to refine and expand the model nationally.