Patients and their caregivers are often unprepared to care for themselves in the next care setting [25]. Causes for readmissions are multifactorial and include issues such as lack of adherence, inadequate discharge preparation, and education [3]. With the development of patient-reported measures to reflect the patient’s perceived needs at discharge, health-care providers can assess a patient’s “readiness” for discharge and concentrate efforts on quality improvements in discharge planning [12]. Tools such as brief prescriptions, ready to reenter community, education, placement, assurance of safety, realistic expectations, empowerment, and directed to appropriate services (B-PREPARED) and Care Transitions Measure 3 (CTM-3) can be used to assess a patient’s readiness [12].

Inadequate patient education and nonadherence to the medical plan alone may account for as many as 40 % of the readmissions [26]. Assessing a patient’s characteristics such as functional, cultural, and psychosocial aspects is also an important part of the transition of care process [5]. Most programs use eight specific characteristics in their post-discharge disease management, which are patient education; early assessment after hospital admission, including caregivers in the care plan; medication review; early post-discharge follow-up; telephone follow-up; home visits; medication review; and post-discharge handoff to outpatient providers [5]. It is difficult to identify which specific intervention carries the most weight since many institutions use the “bundled intervention approach,” but institutions most successful in reducing rehospitalizations were the ones that included home visits and/or follow-up telephone calls [5].

Barriers such as low health literacy, lack of preparedness on discharge, and a paucity of social support might be addressed with a more structured and individualized patient-centered education program and an increased awareness of outpatient resource availability [7]. As many as 90 million Americans have poor health literacy, and as many as 62 % of patients treated in the ED for heart failure are unable to read the label on a prescription bottle [23]. A more formal and detailed education on disease progression might alleviate anxiety and fear [7, 27, 28]. Discharge instructions should be legibly written and in a patient-friendly format [29]. It is recommended that they are written at the sixth grade reading level; however, most are written at a ninth to tenth grade level [8]. Older individuals may need materials that are written in larger print. In heart failure, teach-back methods were associated with increased patient compliance and knowledge retention as well as decreased hospital readmissions [5]. This method should be employed in all aspects of patient education.

Early identification of patient’s caregivers and their specific roles as well as the patient’s social support system is imperative. Adequate support has been shown to have a positive impact on the patient’s ability to adhere to a self-care program and increased capability of symptom management [5]. Assessing the need for a formal support system such as home care, nursing home, and hospice/palliative care might break several barriers to self-care [5, 30]. Particular attention should be paid to groups of individuals with a greater need for transition of care such as those with increased frailty, those who are non-English speakers, and those with cognitive deficits [5]. A better system for coordination of care in the form of EMR and HIE as well as addressing medication discrepancies and using a low-literacy friendly approach to medication understanding and symptom management are all areas needing improvement [7, 25, 27, 28].

Socioeconomic status is an independent risk factor for readmission with the highest risk for readmission being associated with the lowest income [31, 32]. The average number of medications taken by a patient is 10.5 and increases as the severity of symptoms increase [33]. With the implementation of the Affordable Care Act, health system outcome improvements have been established such as better coordination of care and post-discharge follow-up. Ongoing research focuses on patient-centered outcome interventions on functionality, symptoms, and quality of life (QOL) [5].

It is important that the discharge plan includes medications that are evidence based [34]. The preadmission medication list must be reconciled with the discharge list, and clear written instructions should be given to the patient about what to stop and what to continue or add. The medication plan for the treatment of heart failure can be challenging and complex which may lead to discrepancies, unwarranted side effects, and nonadherence, all of which may contribute to hospital readmissions. Patients with low health literacy and impaired cognition are at highest risk [27].

Loop diuretics were commonly cited as problematic and difficult to adhere to because of disturbing side effects and fear of adverse effects to other organs. New research suggests that a tailored, pharmacist-delivered intervention on medication reconciliation might have a positive impact especially for high-risk individuals [27]. This approach consists of patient-specific counseling specifically assessing the patient’s barriers to understanding and compliance, an illustrated medication schedule, and a pillbox to assist the patient at home [27]. The intervention would conclude with a follow-up telephone call after discharge, and if problems were detected, pharmacists would provide the needed assistance [27].

Another concern is the interaction between over-the-counter medications and herbal products. Patients seldom tell the health-care provider about the over-the-counter medications and herbal therapies they are taking. Because there are many possible drug-to-drug interactions, it is best to encourage patients to discuss all medications and supplements that they are taking and to maintain a written record of all.

Nonadherence to dietary restrictions can lead to worsening symptoms and subsequent readmissions [22, 34, 35]. Few patients have the knowledge of how to follow a low-sodium diet, and only 36 % report following dietary recommendations [23, 36]. New guidelines from the American Heart Association recommend limiting sodium to 1500 mg/day for patients with stages A and B heart failure because of the data linking its intake to heart failure risk factors such as hypertension, left ventricular hypertrophy, and other cardiovascular diseases. Currently, there is insufficient data to support definitive sodium restrictions in those with stages C and D heart failure [37]. Discharge instructions for the patient with heart failure should include a clear diet plan with examples of foods to avoid and how to read a food label. It has been reported that up to 42 % of patients with heart failure are poor at reading food labels [23].

Some patients also need to restrict fluids. Alarmingly, 38 % of patients with heart failure report thinking they are required to drink large quantities of fluids [38]. Those with persistent fluid retention or severe hyponatremia, despite a low-sodium diet and diuretics, may benefit from a fluid restriction [23]. These individuals will need instructions on how to measure fluid intake and ways to address the sensation of thirst.

The activity plan should be tailored to the individual [23]. Patients need to be reassured that activity is beneficial and receive instructions on how to monitor their tolerance and symptoms. Exercise has been shown to improve oxygen delivery, decrease inflammation, increase peak oxygen uptake, and decrease depression [23].