Control group patients received care routine for the
admitting hospital, including site-specific heart failure–
patient management and discharge planning critical paths
and, if referred, standard home agency care consisting of
comprehensive skilled home health services 7 days a week.
Standards of care for all study hospitals include institutional
policies to guide, document, and evaluate discharge
planning. The discharge planning process across hospital
sites was similar. The attending physician was responsible
for determining the discharge date, and the primary
nurse, discharge planner, and physician collaborated in
the design and implementation of the discharge
plan. Standards and processes of care for the primary home
care sites were also similar. These included use of liaison
nurses to facilitate referrals to home care; availability of
comprehensive, intermittent skilled home care services in
patients’ residences 7 days per week; and on-call registered
nurse availability 24 hours per day. Fifty-eight percent (71/
121) of the control group received referrals for skilled
nursing or physical therapy after the index hospital
discharge.