Abstract
A Joint Commission Certified Advanced Heart Failure (HF) Program based out of tertiary care center with a 24% 30 day readmission rate was seeking another step to further reduce early re-hospitalization. We looked to an improved communication with home health nurses (HHN) as an answer. HHN are the experts in managing chronic illness within the home setting and HF nurses and nurse practitioners (NP) are the experts in this particular disorder. If HHN could gain the skill and confidence in more advanced HF assessment and treatment, they would bring greater skills to the patient at home and improve communication with the HF NPs. This lead to the development of a three part educational program designed to improve outcomes of HF patients seen after hospital discharge.
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