The ability to maintain contact with heart failure patients
both in and out of the hospital allows for continuity
of care, continued reinforcement of education
provided, and ongoing assessment of adherence with
the core measures. By implementing a comprehensive,
ACNP-led patient management program for heart failure,
overall adherence to Joint Commission recommendations
for the care of heart failure patients was achieved to nearperfect
levels. Collaboration between and among physicians,
nurses, case managers, and personnel from admitting,
laboratory and information technology resulted in
a multifaceted approach that consistently afforded timely
identification of patients with heart failure. Once identified,
patients received close, daily monitoring of important
quality indicators that resulted in a reduction in variation
and very high quality, consistent care. Research is
needed to determine if this multidisciplinary, ACNP-led
approach is useful in improving patient quality of life
and/or organizational outcomes for heart failure patients
admitted to acute care hospitals.