Table 3. Stakeholders and interventions.

IV= Intravenous; IDR= Interdisciplinary rounds; SWA= Social worker assistant; DSRIP= Delivery system reform incentive payment

Stakeholders	Interventions
Clinical triggers	Pro Brain Natriuretic Peptide > 300, IV loop diuretics
Case Managers	Verify active heart failure patients during IDR
House Staff	Utilize “power-plan” with high-risk Heart Failure consult
Clinical Pharmacist	Reconciliation of medications on admission and discharge
Social Work/SWA	Deliver medications directly to beds
Registered Dieticians	Education completed on all heart failure patients
Volunteers	Discuss heart failure education booklets and make follow-up phone calls within 48 hours post-discharge
Home Care Nursing	Referrals for home nursing or social needs; supply scales
DSRIP goal	Schedule follow-up appointments to see a primary care physician/cardiologist within 7-14 days