Heart failure management across the continuum: a communication link.

Patients with heart failure often become lost in the ambulatory healthcare maze on hospital discharge. This causes fragmentation of care due to a lack of a communication link with the ambulatory setting. This article discusses a quality improvement project and addresses the use of a communication tool that helps to transition the plan of care for the heart failure patient from acute care to the ambulatory care setting. The key points focus on the continuance of the plan of care that began during hospitalization and is then extended into the ambulatory setting through care management services.