Patient care heart failure model: the hospitalization to home plan of care.

This article details a heart failure care model at North East Veterans Affairs (VA) Medical Center. The North East VA health system has been involved in quality improvement of heart failure care for many years. This involves continuous quality improvement in the full spectrum of treatment from admission through discharge and outpatient follow-up. Improving patient care is always the main goal. Assisting patients to better understand self-care concepts is key to avoiding heart failure exacerbations. Educating patients to identify problematic symptoms early and access the system for help can often avoid costly readmissions. The case study provided in this article highlights the journey of a heart failure patient treated at this VA hospital and the care coordination process, which is necessary for good patient care through use of multidisciplinary team members.