Abstract
Background: Our Nurse Without Borders program started in January, 2006 to see all heart failure patients in the hospital for education, verifying CHF core measures, screening for depression and sleep apnea. We have used the Cardiocom scale for telehealth management of frequent CHF readmissions for the past 10 years. A nurse phones patients at home within 30 days of discharge. Our hospital has the lowest CHF readmission 21.2% for the state vs 24.9% for the nation. We utilize a multidisciplinary outpatient heart failure clinic however we still needed to improve. Using H2H (Hospital to Home) initiative started by American College of Cardiology, we want to be even more aggressive in decreasing our CHF readmissions.
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