After completion of the training program, APNs
assumed responsibility for discharge planning while the
patient was hospitalized and substituted for any visiting
nurse services that might have been ordered at discharge
during the 3 months after hospital discharge. During the
patient’s hospitalization, a comprehensive patient assessment
using valid and reliable instruments was conducted
that addressed the following: patients’ and caregivers’
goals; nature, duration, and severity of heart failure and
comorbid conditions; physical, cognitive, and emotional health status; general health behaviors and skills; and availability and adequacy of social support.