Abstract
Case managers are an integral part of the care transition from the acute care setting back to the community. Often, it is the case manager leading this effort through various interventions. Findings from this quality improvement project suggest the use of the evidence-based, four-pronged approach to discharge planning for the heart failure patient population reduced the risk and rate of heart failure-related readmissions for the involved nursing units. These findings also surmise that there is a correlation between the number of interventions and the rate of readmission.