Background Unplanned readmission in the heart failure patient is significant. Each subsequent hospital admission can lead to declining health and functional status for the patient. The time of transition from inpatient care to home is crucial for providing the information and resources to ensure successful care outside the hospital. While several studies show limited success with various strategies such as post-discharge phone calls or coaching, the use of a standardized plan utilizing consistent education by a dedicated Nurse Navigator, Pharmacist discharge counseling, scheduling of follow-up appointments, and a post-discharge call or follow-up has not been evaluated. Objective The objective of this study was to determine the effectiveness of a standardized transition of care plan at hospital discharge on the readmission rate of heart failure patients. Methods All patients (n=43) identified as heart failure patients by the Nurse Navigator during admission were evaluated for compliance with the identified elements. Readmission rate for the patient population was calculated and compared to patients with a primary diagnosis of heart failure during the same period for the previous year (baseline data). Compliance with the four components of the transition of care bundle - consistent education, discharge counseling, follow-up appointments scheduled prior to discharge, and a post-discharge follow-up - was evaluated. Results Analysis of data showed that 91% of patients received education from the Nurse Navigator during hospitalization. 70% were counseled on medications by a pharmacist prior to discharge. Follow-up appointments with either a Primary Care Physician (PCP) or Cardiologist were made for 91% of patients. The number receiving a follow-up phone call, or visit by the Nurse Navigator during a routine visit to the Congestive Heart Failure Clinic was 70%. The overall readmission rate for the population was 16.28% (7 of 43 patients). This represents readmission of the same number of patients as seen in the baseline data. Patients who received three or four interventions had a lower readmission rate at 13.89% compared to those with only 1 or 2 interventions at 28.57%. None of the patients who received a follow-up phone call from the Nurse Navigator returned to the hospital within 30 days. In addition, based on information collected during follow-up phone calls by the Nurse Navigator, all patients were able to describe their diagnosis and felt that their condition had improved since hospitalization. All patients had a supply of their medication and planned to keep their follow-up appointment. Conclusion Transition from hospital care to home is a difficult proposition for patients and families. The implementation of a standardized plan for this care transition resulted in a lower readmission rate when 3 or 4 of the selected interventions were implemented. In addition, post-discharge phone calls indicate that these patients are more knowledgeable about their disease process, medications, and care and may have a lower risk for readmission. Overall, the implementation of a standardized plan for care transitions in the hospitalized heart failure patient proved to be a success.