In-home heart failure follow-up could benefit women, younger patients 

New York, NEW YORK (September 15, 2025) – Mobile integrated health (MIH) can help heart failure patients transition from the hospital to home, and may offer additional benefits to women and younger patients, Columbia Nursing researchers report today in JAMA Internal Medicine.  

Heart failure is the number one cause of hospitalization for older adults in the U.S., and up to 25% of Medicare beneficiaries hospitalized for heart failure are readmitted within 30 days of discharge. Professor Ruth Masterson Creber, PhD, director of the Center for Community-Engaged Informatics and Data Science, and her colleagues note that MIH and a transitions of care coordinator (TOCC) have both shown promise in improving outcomes for these patients, but their effectiveness has not been compared.  

In the Mighty-Heart trial, Professor Masterson Creber and her colleagues randomly assigned more than 2,000 patients hospitalized for heart failure from 11 New York City hospitals to either TOCC (a follow-up call from a nurse within 48-72 hours of discharge) or TOCC plus MIH (additional nurse care coordination, community paramedic home visits, and telehealth with emergency medicine physicians).  

At 30 days after discharge, 20% of patients in each group had been readmitted to the hospital, and there was no significant difference between the two groups in health status or health care utilization. However, MIH was associated with better health status among patients younger than 70. Women in the MIH group were 30% less likely to be readmitted to the hospital for any cause and 36% less likely to be admitted for heart failure compared to the TOCC only group. 

“Patients facing greater social and economic barriers—like financial stress or lack of caregiving support—may gain the most from mobile integrated health,” Masterson Creber notes. “These findings highlight the complexity of tailoring care transitions in heart failure—and reinforce the need for novel care models that deliver high-quality care to the patients who need it most.” 

The study was funded by the Patient-Centered Outcomes Research Institute (PCORI). Other Columbia Nursing authors included Assistant Professor of Nursing Megan Reading Turchioe and Professor of Data Science Yihong Zhao, PhD. All study faculty are in the Center for Community-Engaged Informatics and Data Science.  

About Columbia University School of Nursing  

Columbia University School of Nursing is advancing nursing education, research, and practice to advance health for all. As one of the top nursing schools in the country, we offer direct-entry master’s degrees, advanced nursing, and doctoral programs with the goal of shaping and setting standards for nursing everywhere. And, as a top recipient of NIH research funding, we address health disparities for under-resourced populations and advance equitable health policy and delivery.    

Through our expansive network of clinical collaborations in New York City and around the world —including our dedicated faculty practice, the ColumbiaDoctors Nurse Practitioner Group — we cultivate a culture of innovation and diversity and champion a community-centered approach to care. Across the Columbia Nursing community, we encourage active listening, big thinking, and bold action, so that, together, we’re moving health forward.  

Columbia University School of Nursing is part of Columbia University Irving Medical Center, which also includes the Columbia University Vagelos College of Physicians and Surgeons, the Mailman School of Public Health, and the College of Dental Medicine.