"Pathfinding on the Frontier" (In the Community, October 2015) shows how nursing care coordinators can make a difference in patients' lives. In the rural facility in which I work, we recently implemented a similar program in an effort to reduce readmissions. Originally, this program only included patients with heart failure who had been discharged, but we soon expanded it to include all patients discharged from our facility.

Among patients who were readmitted within 30 days, we found that many hadn't kept follow-up appointments, which had been made for them before they left. In an effort to improve patient compliance with the postdischarge plan of care, a case manager now calls each patient one week after discharge to ensure that she or he has kept any follow-up appointments and has filled prescriptions.

Julie Miller, BSN, RN, CPHQ

Smithville, TX