Readmissions for patients with chronic conditions are both unpleasant for patients and expensive for the healthcare system. South Nassau Communities Hospital in Oceanside designed and implemented a "Heart Healthy Bundle" to promote patient self-management as part of the transition home for heart failure patients. Educational materials were standardized, a "teach back" approach was adopted to measure patient learning, and patients are now coached to keep a daily weight log.
Using the FACES (fatigue, activities limited, chest congestion, edema (ankle swelling), shortness of breath) acronym, patients now learn to recognize early warning signs to report to their physician. A heart failure coordinator visits patients regularly, follow-up appointments are scheduled, callbacks are made within two business days of discharge, and a "hotline" is available to answer patients' questions. Palliative Care consultations are encouraged, home care referrals are made, and outreach to local nursing homes includes heart failure education. As a result, heart failure readmission rates at South Nassau have decreased by more than 40%, dropping from 25.5% to 15.2%.