A poorly executed transition from hospital to home negatively impacts a patient's health, family resources and unnecessarily increases the costs to the health care system, patients, families and communities. The purpose of the project was to implement a process for discharging heart failure (HF) patients and to evaluate how this process influences the readmission and/or unplanned return rates over the first 30 days following discharge. Over a 3 month period of time all patients (n = 18) with a discharge diagnosis of HF who returned to their home after discharge were enrolled in the project. The intervention consisted of patient education, provider availability and accountability post-discharge, medication reconciliation, transfer of information to post-acute care providers, and "hand-off" to home health or hospice. The patient received a scripted follow-up telephone call at 24 to 72 hours following discharge. On telephone follow-up patient's had difficulty remembering information taught to them during their hospitalization. Profound difficulty was noted with questions related to reading and/or interpreting numbers. Age, illiteracy, diminished cognition, timing and the hospital environment were not conducive to the teaching-learning interaction and may have contributed to the poor recall of information from pre discharge to post discharge. The rates of readmissions/returns over 3 months were compared with those for a comparable timeframe for 2007- 2008. No statistically significant differences in the rates of readmissions or returns was found.