Institute for Healthcare Improvement. Improvement Stories. 2008. http://www.ihi.org/resources/Pages/ImprovementStories/StLukesHomeCareNeedsAnticipatedatDischarge.aspx. Accessed 8/13/14. For some patients, being discharged from the hospital is a mixed blessing. It can feel both great and scary to return home, especially for those who need to take on new and potentially confusing responsibilities for self-care. At St. Luke’s Hospital in Cedar Rapids, Iowa, part of the Iowa Health System, a program called Transitions Home is addressing these concerns for patients with heart failure. By providing self-management support for patients at home, the hospital is reducing its rate of readmissions for heart failure patients. The program includes a combination of patient-friendly written information along with a home visit from a nurse, a physician office visit, and follow-up telephone calls. There are also weekend classes on heart failure management and diet, designed to anticipate patients’ need for ongoing reinforcement and support.