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A post-discharge follow-up program for congestive heart failure (CHF) patients has decreased the readmission rate by more than half at Harper University Hospital in Detroit. Nurse case managers specially trained to do triage assessment by telephone follow up with the CHF patients after discharge, making sure patients monitor their weight and blood pressure on a daily basis and reinforcing the patient education instructions patients received during their hospital stay.

Telephonic program cuts CHF readmissions in half