Despite efforts to improve the discharge planning process and subsequent outcomes, existing mechanisms fail to accurately identify elders' needs for follow-up care. Studies report rehospitalization rates ranging from 12 to 50%. The two aims of this study were to (1) examine the difference in outcomes for elders hospitalized with heart failure and caregivers who participated in a professional-patient partnership model of discharge planning compared to those who received the usual discharge planning and (2) examine differences in costs associated with hospital readmission and use of the emergency room following hospital discharge. A before-and-after nonequivalent control group design was used for this study. Data were collected from the control and the intervention cohorts before discharge and at 2 weeks and 2 months postdischarge. One hundred and fifty-eight patient-caregiver dyads completed both the predischarge and 2-weeks postdischarge interviews; 140 also completed a 2-month follow up. The average age of elders was 73.7 years; the average age of the caregivers was 58.5 years. The findings indicated that elders in the intervention cohort felt more prepared to manage care, reported more continuity of information about care management and services, felt they were in better health, and when readmitted spent fewer days in the hospital than the control cohort. Caregivers in the intervention cohort also reported receiving more information about care management and having a more positive reaction to caregiving 2 weeks postdischarge than the control cohort.