Diary users showed evidence of improved clinical and hospital outcomes. Further investigation is needed to clarify the characteristics of a diary user and the effect of diary use on self-management and outcomes.

BackgroundHeart failure (HF) patients have high rates of hospitalization and rehospitalization.Methods and ResultsA protocol‐driven clinic staffed by an allied health care team was designed for patients discharged from the hospital with a diagnosis of congestive HF. The clinic provided follow‐up visits 1 week and 4 to 6 weeks after hospital discharge. One‐hundred and fourteen patients were observed at least 1 time, and 80% of these patients completed the 2‐visit protocol. Clinical evaluations were provided by a nurse practitioner specializing in HF and a clinical pharmacist; these evaluations included physical examination, laboratory evaluation, medical education and reconciliation, medication adjustment and titration, and care coordination. Referrals to home health and appropriate services were provided. At visit 1, 25% of patients were hypervolemic and 13% were hypovolemic. At visit 2, 20% were hypervolemic and 13% were hypovolemic. Medicine reconciliation errors were common, with an average of 2.1 and 0.8 errors per person recorded for visits 1 and 2, respectively. Clinic participants showed a 44.3% reduction in 30‐day readmission rates, as compared to the hospital's average 30‐day readmission rates.ConclusionsProtocol‐driven postdischarge transition care delivered by allied health staff addressed multiple transition issues and was associated with a dramatic reduction in readmission rates.

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