Her role combines the medical management of CHF, including physical evaluation, diagnosis, and disease management, with the nursing component of patient education and telephone follow-up. Donna McCauley is the continuum of care manager, who not only follows the heart failure patient during admission, but also develops appropriate discharge plans. As a clinical nurse specialist (CNS), she monitors the acute care stay of complex cardiac patients. She evaluates daily the care and outcomes of the patient’s hospitalization to ensure smooth progression throughout the acute management phase. During this phase, complex discharge needs are identified and communicated to the CHF nurse practitioner.