Original ArticlesTransitional Care Home Visits Among Underserved Patients With Heart FailureArnold, Erica R. DNP, RN, CNL, CHFN, CCCTM; White-Williams, Connie PhD, RN, NE-BC, FAAN; Miltner, Rebecca S. PhD, RN, CNL, NEA-BC; Hites, Lisle PhD, MS, MEd; Su, Wei PhD; Shirey, Maria R. PhD, MBA, RN, NEA-BC, ANEF, FACHE, FNAP, FAANAuthor Information University of Alabama at Birmingham Hospital (Dr Arnold); Center for Nursing Excellence, and Heart Failure Transitional Care Services for Adults (HRTSA) Clinic, University of Alabama at Birmingham Hospital (Dr White-Williams); The University of Alabama at Birmingham School of Nursing (Drs White-Williams and Miltner); Community Medicine & Population Health, College of Community Health Sciences, Institute for Rural Health Research, The University of Alabama, Tuscaloosa (Dr Hites); The University of Alabama at Birmingham School of Public Health (Dr Su); and Clinical and Global Partnerships, Jane H. Brock—Florence Nightingale Endowed Professor in Nursing, The University of Alabama at Birmingham School of Nursing (Dr Shirey). Correspondence: Erica R. Arnold, DNP, RN, CNL, CHFN, CCCTM, Department of Care Transitions, University of Alabama at Birmingham Hospital, 619 9th St South, Jefferson Towers Room 1218 C, Birmingham, AL 35294 (firstname.lastname@example.org). This project was supported in part by the Health Resources & Services Administration (HRSA) of the US Department of Health & Human Services (HHS) under grant #UD7HP26908 (Interprofessional Collaborative Practice Enhancing Transitional Care Coordination in Heart Failure Patients), July 2014 to June 2017 ($1.5 million, Shirey, PI). The information or content and conclusions presented are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government. The University of Alabama at Birmingham (UAB) Hospital contributed sustainable funding beyond the grant funding period for clinic operations (White-Williams, senior director). The authors declare no conflict of interest. Nursing Administration Quarterly: July/September 2020 - Volume 44 - Issue 3 - p 268-279 doi: 10.1097/NAQ.0000000000000426 Buy Metrics Abstract Heart failure (HF), a global public health problem affecting 26 million people worldwide, significantly impacts quality of life. The prevalence of depression associated with HF is 3 times higher than that of the general population. Evidence, though, supports the use of transitional care as a method to enhance functional status and improve rates of depression in patients with HF. This article discusses the findings of a quality improvement project that evaluated health outcomes in underserved patients with HF who participated in a transitional care home visitation program. The visitation program exemplifies the role of leadership in facilitating transitions across the health care continuum. The 2-year retrospective review included 79 participants with HF. Comparisons of outcomes were made over 6 months. Although not statistically significant, clinically significant differences in health outcomes were observed in participants who received a home visit >14 days compared with ≤14 days after hospital discharge. A home visitation program for underserved patients with HF offers opportunities to enhance care across the continuum. Ongoing evaluation of the existing home visitation program is indicated over time with the goal of offering leaders data to enhance patient and family-centered transitional care coordination. © 2020 Wolters Kluwer Health, Inc. All rights reserved.