The AACN Synergy Model for Patient Care describes a framework for nursing practice. The key to this model is the linkage of patient characteristics with nurse competencies to achieve optimal patient outcomes.1 The Synergy Model is readily adaptable to the acute care or critical care setting when the patient is critically ill and the intensive care nurse links his or her own competencies to the patient’s characteristics. However, not all acute care is conducted within the walls of the hospital setting. Today’s healthcare environment mandates that patients with serious diseases live in their homes, causing the need for acute and critical care settings to reach out to their patients not only to assist them in maintaining a quality of life but also to decrease costs of hospital readmissions. This situation is especially true for patients with chronic heart...

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