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HEart Failure Discharge Initiative

There are 23 million people with heart failure worldwide and approximately 5.8 million with this condition in the United States.1,2 In the U.S., 1 million hospitalizations for heart failure (HF) occur annually, accounting for over 6.5 million hospital days and an estimated 37.2 billion dollars is spent each year on heart failure.

Rates of rehospitalization continue to rise, approaching 30% within 60 to 90 days of discharge.3 In response to this problem, the Centers for Medicare & Medicaid Services (CMS) has required Medicare to reduce these readmission rates by reducing payments to hospitals.The problem is enormous and much is being attempted and written about reducing readmissions.

Practical solutions can often be overlooked when tackling such a complex issue. The HEFDI Group was formed to develop hands-on solutions to overlooked areas which can positively impact the continuum of care for heart failure patients and potentially reduce readmissions. The group is comprised of clinicians with decades of expertise in both the care and research of heart failure patients.

This ongoing initiative is supported through an educational grant from Alere, Inc.

  • McMurray JJ, Petrie MC, Murdoch DR, Davie AP. Clinical epidemiology of heart failure: public and private health burden. Eur Heart J. 1998;19 Suppl:P9.
  • WRITING GROUP MEMBERS, Lloyd-Jones D, Adams RJ, et al. Heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation. 2010;121(7):e46-215.
  • Gheorghiade M, Vaduganathan M, Fonarow GC, Bonow RO. Rehospitalization for heart failure: problems and perspectives. J Am Coll Cardiol. 2013;61(4):391-403.


As Associate Chief Nursing Officer of the Office of Nursing Research and Innovation, Dr. Nancy Albert administers and provides services throughout the Cleveland Clinic Health System, conducts her own program of research, and mentors nurses in research and evidence-based practice. Her programs of research currently focus on two themes: understanding bio-behavioral issues that impact self-care adherence and clinical outcomes of patients with heart failure, and improving conformity to recommended heart failure care advocated in national guidelines. Dr. Albert is a clinical nurse specialist (CNS) in a disease management clinic for patients with advanced heart failure, and an external consultant and educator to nurses and healthcare teams wishing to promote evidence-based nursing practices and nursing research.

In addition to her clinical and education work, Dr. Albert is actively involved on steering committees, work groups, and task forces of many healthcare related organizations that are focused on improving quality of care and clinical outcomes, including the American College of Cardiology and the American Heart Association. She has gained both local and national recognition for her work in nursing, research, and lecturing, and in 2014 received the Cleveland Clinic Nursing Institute Lifetime Achievement Award.

Beth Davidson, DNP, ACNP, CCRN, CHFN

Beth has 20 years experience in cardiac and critical care nursing. She has worked as a staff nurse, clinical nurse specialist, heart transplant coordinator, and nurse practitioner providing care to patients with cardiac diagnoses. Beth is currently the Director of the Heart Failure Disease Management Program at Centennial Medical Center. She received her Master’s Degree from Vanderbilt University and a Doctor of Nursing Practice degree in 2007 from the University of Tennessee Health Sciences Center. She has published/presented on the topics of heart failure and transplantation. Beth is currently serving on the AAHFN Board of Directors and is co-founder of the Middle Tennessee Heart Failure Journal Club.

James L. Januzzi Jr., MD, FACC

Dr. James Januzzi is currently the Roman W. DeSanctis Endowed Distinguished Clinical Scholar in Medicine at the Massachusetts General Hospital and Hutter Family Professor of Medicine at Harvard Medical School.  He is also a faculty member at the Harvard Clinical Research Institute.  Dr. Januzzi has contributed greatly to the understanding of cardiac biomarker testing, where his work with the natriuretic peptides and troponin has set international standards for use in diagnosis, prognosis, and management of patients suffering from acutely decompensated heart failure, chronic heart failure as well as those with acute coronary syndrome.  He has published more than 400 manuscripts, book chapters, and review articles, has edited two text books on cardiac biomarker testing.  He is on the editorial board of numerous scientific journals, including current service as an Associate Editor at the Journal of the American College of Cardiology: Heart Failure.  He was the chairman of the NT-proBNP Consensus Panel, is the lead author of the Heart Failure Section for the Universal Definition of MI Biomarker Task Force, was a section editor and member of the working group for the 2013 ACC/AHA Clinical Practice Guidelines for Heart Failure, and is a member of the Heart Failure Society of America.

Ann S. Laramee, MS, ANP-BC, ACNS-BC, CHFN

Ann Laramee is a Clinical Nurse Specialist and Nurse Practitioner for the Cardiology and Palliative Care Services at University of Vermont Medical Center. She is a clinical educator and adjunct faculty for Master’s and Doctoral students at the University of Vermont in Burlington, VT. Ann’s areas of expertise and research interests include heart failure care management, palliative care, evidence based practice, and health literacy with numerous publications and national presentations in each area. She currently serves on the Advocacy Committee for the Heart Failure Society of America, the Membership Committee for the American Association for Heart Failure Nurses, Membership Chair for the Vermont State Nurses Association and Governance Chair for Kappa Tau, the local chapter of Sigma Theta Tau International Nursing Honor Society. To compliment her practice as an advance practice nurse, Ann is also a Bowenwork Practitioner.

Maria Fe White, NP, FNP/ACNP-BC

Maria Fe White is a Nurse Practitioner specializing in the care of patients with Heart Failure. She currently works as a Lead Nurse Practitioner at Cedars Sinai Medical Center in Los Angeles, California. She is an integral member of the multidisciplinary Advanced Heart Disease team, managing patients with cardiomyopathy in both the inpatient and outpatient settings, managing transitions of care, and heart transplant evaluation. Prior to joining the advanced heart team at Cedars Sinai Medical Center, Ms. White worked as a Nurse Practitioner at the Ahmanson Cardiomyopathy Center at UCLA and in the private practice setting.

Miss White participated in many research projects in the area of cardiovascular nursing and heart failure. She is actively involved in various professional organizations and steering committees, such as the Heart Failure Society of America, American College of Cardiology and California Association of Nurse Practitioners, American Association of Heart Failure Nurses. In the past, she has served as the Education Committee Chair of the California Association of Nurse Practitioners and Past President of the Los Angeles Chapter of the American Association of Critical-Care nurses. She currently serves as the Co-Chair of the Nursing Committee of the Heart Failure Society of America. She works tirelessly as a liaison of the Southern California Chapter of the American College of Cardiology. In 2013, she received her designation as an Associate of the American College of Cardiology.

Ms. White is an Associate Professor (WOP) at the UCLA School of Nursing, Acute Care Nurse Practitioner track. She has given numerous presentations locally, nationally, and internationally on topics related to heart Failure, care transitions, and general cardiovascular care.

Her non-clinical cardiovascular activities include biking, running, hiking and other physical activities. She enjoys teaching group yoga and resistance training exercise at a local gym. As a certified yoga teacher, she volunteers her time teaching complimentary classes in the community and nursing education events.