Patient selection:
(1) age >= 70 years of age
(2) hospitalized for congestive heart failure
Risk factors for readmission within 90 days of discharge:
(1) prior history of heart failure (previous to current admission)
(2) >= 4 admissions within the previous 8 years
(3) heart failure precipitated by acute myocardial infarction
(4) heart failure precipitated by uncontrolled hypertension (> 180/100)
Preventable or remediable risk factors associated with early readmission:
(1) noncompliance with medications
(2) nonadherence with diet
(3) inadequate discharge planning (failure to involve social services and other ancillary support staff)
(4) inadequate followup (failure to involve home care or a prolonged interval to next appointment with the physician)
(5) failure in the social support system (failure in active family involvement)
(6) failure to seek medical attention promptly upon symptom recurrence
