The following steps are what I personally used to reduce my father’s 30-day readmission rate for CHF. My father has CHF, diabetes, high blood pressure, he has to take two types of dialysis six days a week, he has two Ziploc bags of meds that he has to take daily, he weighs 98 lds., and I thank God for him every day. But he will eat a bag of hot skins and drink a beer to watch football (Roll tide)! Here is what I did (to) him to keep him from returning to the hospital in 30 days or less.  Home health, and the physician must discuss with the caregiver and the patient about the process and the importance of being compliant prior to these steps. I feel that the patient truly needs to understand they have a responsibility also or they will feel the consequence.