AHRQ. Agency for Healthcare Research and Quality. Transition Home Program for Patients with Heart Failure http://innovations.ahrq.gov/content.aspx?id=2206. Accessed August 13, 2014. Summary The Transition Home for Patients with Heart Failure program at St. Luke’s Hospital in Cedar Rapids, IA, incorporates a number of components to assure patients a safe transition to home or another health care setting. These components include an ongoing enhanced assessment of postdischarge needs, thorough patient and caregiver education, patient-centered communication with subsequent caregivers at handovers, and a standardized process for postacute care followup. The program reduced the 30-day heart-failure-to-heart-failure readmission rate for patients from 14 to 6 percent, and the all-cause heart failure readmission rate is 15 to 17 percent. See the Description section for several updates related to ongoing assessment and patient education; the Results section for updated data on readmission rate and patient satisfaction; and the Planning and Development section for new information about spread to other conditions and an Advance Medical Team pilot (updated February 2013).