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| Usual care | Intervention |
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| Disease-specific information provided in two-page HF handouts. | HF information about incidence, prognosis, sodium restriction hints, links to HF organizations, list of HF-related resources at the facility. |
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| Staff verify date/time of follow-up appointment. | Verifying: whether transportation was available at the scheduled appointment, if each prescription was obtained at discharge, and what questions the provider will ask at followup. |
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| Staff confirm the patient knows the phone number of his/her outpatient clinic. | Provided nurse facilitator name/phone as well as clinic name and phone |
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| Follow-up phone call asks general question: “Are you doing OK?” “Did you pick up your prescriptions?” | A set of HF-specific questions is asked in conversation on follow-up phone call, carefully constructed to avoid questions that lead to an automatic “Yes” or “No” from the patient. |
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| Inpatient staff typically work 12-hour shifts; during a 3-4 day stay, continuity of staff is unlikely. This makes information exchange inconsistent, repetitious, or overlooked. | Nurse facilitator was present Monday through Friday; if not, specific nurse replacement’s name was given to the patient. |
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| Time interval for postdischarge appointment is not set by policy; date/time is generated according to open vacancies. | Study obtained administrative policy support to allow nurse facilitator to require postdischarge followup within five to ten days, even if provider had to be overbooked. |
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| No teach-back method used. Understanding of what patient learned not confirmed. | Teach-back method used. Patient explained the educational information received back to the practitioner. |
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| Staff nurses spend approximately 20 minutes per encounter per patient prior to discharge. | Nurse facilitators spend approximately 45 minutes per encounter per patient prior to discharge. |
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