In aggregate, the various strategies deployed by clinicians to keep HF patients well and out of the hospital are classified under the rubric of multidisciplinary HF disease management.  Operationally, HF disease management differs in its specifics from institution to institution, but typically includes a few core components.

The first is often nurse or pharmacist-led predischarge education, in order to educate and provide patients with the substrate and tools to self-manage their disease.

The second is nurse-directed coordination of care at the time of discharge, to facilitate continuity of care and a warm handoff from inpatient to outpatient providers.

Finally, there is some component of postdischarge surveillance.  In many hospitals this includes both periodic trans-telephonic surveillance of weight and vital signs (telemonitoring) and access for patients who are developing worsening symptoms to providers with specialty expertise in HF.

When applied effectively, HF disease management is extremely effective in improving HF outcomes. In meta-analyses these interventions are associated with a 25% reduction in overall mortality, a 26% reduction in HF readmissions, and about a 19% reduction in hospitalization for any cause over time.^[5]

The advantage to HF disease management is that because of the savings from prevention of readmissions, which is such an important cost driver, these programs are often cost-saving or cost-neutral.  In the end, although it is difficult to say specifically which components are the most relevant, a central focus on early identification  and treatment of worsening congestion is common to all.