Managing Heart Failure in the Hospital: A Practical Approach for Hospitalists
A seasoned hospitalist and an internal medicine physician walk through the real-world challenges of managing heart failure in the hospital — from navigating readmission risk to applying guidelines when time, resources, and follow-up are limited.
Dr. Gregory Gibson is a hospitalist with years of experience treating medically complex patients, many of whom present with heart failure as a primary diagnosis or a comorbid condition. Hospitalists manage the bulk of inpatient heart failure care, which comes with persistent challenges, including diagnostic uncertainty, tight timelines, and pressure to reduce readmissions.
Gibson sees heart failure not as a single diagnosis, but as a high-stakes system of decisions. “It’s always a risk-benefit [analysis],” he says. “You're always trying to strike a balance and be practical about it."
These patients are often older, frequently multimorbid, and sometimes unsupported at home—making transitions of care just as critical as the interventions in the ward.
Gibson appeared on CMEssentials, Oakstone’s audio series for hospital-based clinicians, to share insights into what actually works in managing inpatient heart failure. His approach is rooted in pragmatism, not perfection—and shaped by years of hands-on experience managing this evolving and complex condition. Here’s what he had to say.
Readmissions Are a Symptom, Not the Problem
Heart failure remains one of the top reasons for readmission, and hospitals are under constant pressure to drive those numbers down. But Gibson is quick to point out that you can’t improve readmissions with discharge planning alone, especially if that planning starts the day before discharge.
“We know that’s a big risk factor for poor outcomes,” he says. “What can we do in the hospital to set them up for success?”
Answering this question starts with assessing the risk landscape. Which patients are going back to an empty house? Who has no reliable way to pick up a prescription? Who has no primary care physician? Which patients face a six-week wait to see cardiology? These aren’t edge cases. They’re daily realities.
Gibson calls for earlier discharge planning, ideally at admission. This process requires input from pharmacy, case management, social work, and the bedside team. When heart failure care fails, it’s usually because these voices weren’t in the room early enough.
The care plan has to evolve over time. Day one might focus on determining the patient’s baseline, including their home medications, support system, and recent decompensations. By day two or three, case managers should be working on follow-up logistics while the pharmacy identifies affordable medication options. By discharge, the patient needs to understand what meds to take, why they matter, and what red flags should prompt a call or return.
Medication reconciliation is a critical part of this process. Patients are often admitted while on outdated or incomplete regimens. Staff coordination is required to clarify patients’ guideline-directed medical therapy (GDMT) status, adjust for renal function and hemodynamics, and ensure they’re discharged with a safe, evidence-based plan. Patient education is also crucial, but often rushed.
Readmission risk can also change during a hospitalization. A patient who looks stable on day one may develop volume overload again by day four, or the patient might emotionally disengage from the care plan. Hospitalists must remain vigilant both for clinical decompensation and care plan failure.
The best way to avoid a bounce-back isn’t to add a day in the hospital. It’s to build a discharge plan that doesn’t collapse under real-world pressure.
Guidelines Are Only as Good as Their Application
Heart failure guidelines are rigorous, comprehensive, and continually updated. But for busy hospitalists, implementation isn’t always straightforward. Patients rarely present with textbook physiology, and even when they do, the next steps can be unclear.
Dr. Joseph Sweigart, a hospitalist with the University of Kentucky, speaks to that complexity. “Guideline-directed medical therapy is important,” he says. “But the real work is figuring out how to do that for this particular patient, in this particular moment, with the time and resources you have.”
That might mean holding off on a beta-blocker and prioritizing volume management. It might mean starting one medication in the hospital and handling the rest as part of a clearly documented plan for outpatient care. It might mean acknowledging that an evidence-based therapy isn’t financially accessible to your patient, then choosing the best alternative.
Sweigart views these decisions as crucial to delivering high-quality inpatient care. Medical staff aren’t deviating from standards but rather applying them with up-to-the-moment adaptations. “The best thing we can do is get patients on the right path before they leave our care,” he says. That path doesn’t have to be fully paved, but it has to be navigable.
The sequencing of GDMT is often a sticking point. Should you start with an SGLT2 inhibitor or focus on diuresis and defer initiation? What if the patient’s glomerular filtration rate is borderline, or their systolic blood pressure can’t tolerate a full dose of ACEi or ARNI? Dr. Sweigart advises a flexible, patient-centered approach: Know the targets, but tailor the roadmap.
Clear documentation and handoffs matter here, too. Continuity depends on hospitalists explaining which meds were started or deferred and communicating that treatment plan to outpatient providers. Done well, patients are more likely to stay on the path to full guideline-directed therapy.
Both clinicians agree: The guidelines are a foundation, not a checklist. In the best-case scenario, you’re able to follow every step. In most cases, you’re aiming for stability, safety, and a plan the patient understands and can execute. That’s success.
When the System Is Fractured, Teams Matter More
Hospitalists are often care coordinators in a fractured system. Specialists rotate, outpatient follow-up is delayed, and social complexity gets buried by clinical documentation. In this environment, no one can afford to go it alone.
Gibson advocates for multidisciplinary care—not just as an ideal, but as a functional necessity. He highlights the value of routine collaboration with pharmacy, especially when patients are on complex regimens or transitioning to new heart failure therapies. Case managers play a key role in identifying discharge barriers. Nurses are critical, often spotting early signs of disengagement or decompensation.
“Heart failure is one of those diagnoses that really does lend itself to multidisciplinary team care,” Gibson says. “And you're better off with everyone weighing in.”
The goal of this collaboration is to create clarity. When the team is aligned, decisions happen faster, and follow-through improves. That’s crucial when time is short and the stakes are high.
Gibson recalls one case where a pharmacist flagged a dangerously high-loop diuretic dose the night before discharge. The patient had misunderstood how to take it. A quick correction averted what might have been an avoidable readmission for dehydration. In another case, a case manager discovered a patient couldn’t afford their new meds—and was able to secure a 30-day supply through a foundation program before discharge.
Gibson has seen how the best systems make these touchpoints routine, not reactive. They normalize early team input and build feedback loops into daily care. When something goes wrong—a missed dose or a failed med reconciliation—it’s caught quickly. The process is less about catching people making mistakes and more about creating conditions that lead to fewer mistakes.
Heart Failure Is Messy, but the Best Care Plans Aren’t
Hospital-based heart failure care isn’t about chasing perfection. It’s about managing variables in a way that’s grounded, collaborative, and sustainable. Gibson and Sweigart don’t claim to have all the answers. They offer something better: a model of clinical reasoning that adapts to complexity without being overwhelmed by it.
Their insights remind us that successful heart failure care starts with early planning, honest assessment, and multidisciplinary teamwork. Patient outcomes improve when care teams are adaptable and participate in ongoing education as therapies evolve.
Today’s hospitalists are navigating multiple challenges: guideline changes, patients with increasing social and clinical complexity, and systems under pressure. The stakes are high, but so is the potential impact.
Continue the Conversation With Expert-Led Learning
The landscape of inpatient heart failure care is constantly evolving. Hospitalists are expected to deliver clinically sound, patient-centered care while navigating shifting guidelines, staffing challenges, and the unpredictable realities of real-world medicine.
What experts like Dr. Gibson and Dr. Sweigart make clear is that success is most likely when care teams develop a framework for thinking, adapting, and communicating in complex, time-pressured environments.
When you’re ready to sharpen those skills, Oakstone’s expert-led CME is here to support you. With content that fits into your schedule and addresses the real-world challenges clinicians face, our CME resources are designed to deepen your knowledge and enhance your confidence so you’re ready when it matters most.