A task force at a multihospital health care system partnered with home health agencies to improve gaps during the discharge transition process. A standardized order template for home health nursing and remote telemonitoring was developed to decrease discrepancies in communication between hospital health care providers and home health nurses caring for patients with heart failure. Pilot results showed significantly improved communication with no readmissions, using the order template.
Cardiology (Dr Heeke) and Care Coordination (Ms Schuck), Emory Healthcare, Inc, Atlanta, Georgia; Capstone College of Nursing, University of Alabama, Tuscaloosa (Dr Wood); and Wesley Woods Geriatric Hospital, Atlanta, Georgia (Ms Schuck). Dr Heeke is now with Neurological Surgery, Emory Healthcare, Inc, Atlanta, Georgia.
Correspondence: Sheila Heeke, DNP, RN, FNP-BC, Neurological Surgery, Emory Healthcare, Inc, 1364 Clifton Rd, B2200, Atlanta, GA 30032 (firstname.lastname@example.org).
The authors declare no conflict of interest.
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Accepted for publication: July 15, 2013
Published ahead of print: August 9, 2013