In 2010, the Patient Protection and Affordable Healthcare Act (PPACA) implemented changes to reduce healthcare spending that incorporated Centers for Medicare and Medicaid (CMS) incentive programs to reduce 30-day readmission rates in seniors with heart failure. This project includes a policy and procedure for private practice using a nurse practitioner navigator (NPN) led multidisciplinary team (MDT) for the patient-centered medical home (PCMH) to improve communication between hospitals and PCMH to decrease readmission rates in seniors with heart failure (HF). This practice change will provide an implementation and evaluation plan along with plans for future expansion. Meetings were held twice weekly along with the use of Skype when team members were unavailable. A literature review explored methods to improve communication between hospitals and PCHM to reduce readmission rates. Thirty-two peer-reviewed articles were identified in a search of CINAHL and ProQuest Nursing and Allied Health Source databases that served as the primary pool of evidence used for this project, supplemented by context considerations provided by the project team. Evaluating the evidence based research provided support for this project using a NPN led MDT to reduce readmission rates. Coleman's transition of care (TOC) model was used as a framework for both the policy and procedure to integrate patient, provider, and environmental contexts, support health care policy changes, and reduce health care spending. This scholarly project supports the role of DNPs as leaders in the medical field working to translate existing evidence into policy and practice and lead interdisciplinary health care teams.