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8. Community Management of HF

The management of HF should be delivered within an integrated system of care on the basis of chronic disease management and prevention principles.[559] This system must meet and anticipate the evolving goals and complexity of aging patients throughout their entire journey with HF, and provide access to specialized services, community supports, and end of life care according to patient needs and preferences.

8.1 Patient-level considerations

Clinical complexity, cognitive impairment, and frailty. Aging patients with HF often develop additional medical and psychiatric comorbidities, geriatric syndromes, and associated symptoms. Cognitive impairment, which is more common among patients with HF, is associated with impaired self-care capacity and greater risks of functional decline, rehospitalization, and mortality.[321],[564][567] Similarly, frailty affects up to 50% of older patients with HF, in whom it is associated with nonspecific clinical features, acute care utilization, poor quality of life, worse outcomes from concomitant conditions, and mortality.[568]

Recommendations regarding HF therapy apply to older patients and should not be restricted on the basis of age alone.[180],[182],[569][576] Frail patients are vulnerable to side effects due to the polypharmacy inherent to the treatment of HF and other comorbidities. To avoid side effects such as falls, care must be taken when optimizing medications toward target doses.[564],[577] Orthostatic hypotension is frequent among frail older patients, but if recognized, can be managed to allow for greater use of evidence-based HF therapies.[564],[578],[579]

Frailty has important ramifications on the organization of HF care. It is central to defining patient goals and thus to decision-making related to ACP, surgical treatments, implantable device therapy, medication deprescribing, or other treatments not compatible with these goals.[580],[581] Frailty is more common with age, but can occur in persons who are relatively young chronologically. There is currently no agreement on a single standard frailty measure.[580] Instruments that address key underlying factors related to frailty might be more clinically useful than performance measures, including the Edmonton Frail Scale,[582] the Clinical Frailty Scale,[583] and scales embedded with the interRAI instruments broadly implemented across multiple care sectors in Canada.[580],[584]

An international multidisciplinary working group established, through consensus, Acknowledge, Routinely Profile, Identify, Support, and Evaluate Heart Failure (ARISEHF),[567] a framework to optimize health outcomes for patients with HF. The framework includes acknowledging the importance of multimorbidity, profiling multimorbidity using standardized protocols, and identifying individual patientcentred goals.


168. We recommend that patients with known or suspected HF should be assessed for multimorbidity, frailty, cognitive impairment, dementia, and depression, all of which might affect treatment, adherence to therapy, follow-up, or prognosis (Strong Recommendation; High-Quality Evidence).

Practical Tip

Depression in older patients with HF should be suspected when chronic physical complaints persist despite optimal HF therapy.[560]

Measuring orthostatic vital signs might identify individuals at risk of falls.

Manage fall risk related to orthostatic hypotension:

  • Minimize use of diuretics and other vasodilators by optimizing first-line HF therapy; Consider a medication review with a pharmacist; and Promote physical activity, which might reduce the risk of orthostatic hypotension

Screening, prevention, and management of delirium is a standard of care for all acutely ill older patients, including those with HF.[561]

Cognitive impairment, even when mild, might interfere with HF self-care.

Patients older than the age of 65 years with HF should be screened for cognitive impairment.[562],[563]

If cognitive impairment is identified, a capable substitute decision-maker should be designated.

HF therapies in frail or older patients should be similar to those in younger patients.

In frail older patients, HF medications may be introduced at lower doses and titrated more slowly.

Clinicians should be alert for drug-drug, drug-disease interactions, and therapeutic competition, in cases when the care of one comorbidity is exacerbated by the care of another.[577]

For patients prescribed many medications or those with cognitive impairment, consider adherence aids, such as “blister packs,” to reduce medication errors.

Although the course of HF in individual patients can be unpredictable, a high symptom burden and high mortality rates should be anticipated, and ACP discussions should be initiated early in the course of illness.[564],[585][589] These discussions should focus on the values and goals of the individual patientdwhat they find valuable and important in their lives and what they hope for in the future (eg, attending an important upcoming family event). This is an ongoing conversation to pursue after important clinical events, when considering invasive therapies, or when requested by the patient. Many local, provincial, or federal organizations have excellent tools for helping patients and families in decisionmaking (

Patients with HF suffer from a substantial burden of physical and psychiatric symptoms (Table 37).[590],[591] Palliative care is the promotion of physical and psychosocial health, regardless of diagnosis or prognosis (Table 38).[592] Thus, the delivery of palliative care interventions should be triggered by patient needs and not arbitrarily on the basis of a score on a particular instrument. Several HF-specific and generic quality of life tools have been validated to assess the symptoms of patients with HF, and several are freely available online (Table 39).[584],[593][604] Informal caregivers of patients with advanced HF should be evaluated for coping and degree of caregiver burden. Although several tools exist, there is no clear evidence to recommend one tool over another. Management options for symptoms of advanced HF are outlined in Table 40.[585][589],[605][614]


169. We recommend that clinicians caring for patients with HF should initiate and facilitate regular, ongoing, and repeated discussions with patients and family regarding advance care planning (Strong Recommendation; Very Low-Quality Evidence).

170. We recommend that the provision of palliative care to patients with HF should be on the basis of a thorough assessment of needs and symptoms, rather than on individual estimates of remaining life expectancy (Strong Recommendation; Very Low-Quality Evidence).

171. We recommend that the presence of persistent advanced HF symptoms despite optimal therapy be confirmed, ideally by an interdisciplinary team with expertise in HF management, to ensure appropriate HF management strategies have been considered and optimized, in the context of patient goals and comorbidities (Strong Recommendation; Very Low-Quality Evidence).

Practical Tip

The timing of advance care planning (ACP) discussions should take into consideration the high mortality rate in the year after a first HF hospitalization.

The substitute decision-maker should be involved in ACP discussions.

Engage patients and families in open and honest discussion about the prognosis of HF, including possible modes of death (sudden, progressive HF, or from a comorbidity).

Care preferences and goals of care should be regularly discussed with patients and documented, with emphasis shifting from quantity to quality of life.

As HF symptoms advance, ACP should be reviewed, and the possible deactivation of implantable defibrillators or cessation of invasive therapies such as MCS or hemodialysis discussed, particularly when these no longer align with goals of care.

Symptoms and psychosocial burden (eg, depression, fear, anxiety, social isolation, home supports, and need for respite care) should be regularly evaluated, and a palliative care referral considered.

Informal caregivers of patients with advanced HF should be evaluated for coping and degree of caregiver burden.

8.2 Clinical practice considerations

Multidisciplinary HF management programs have been shown to lead to better symptom control, less acute care utilization, and lower mortality including among older frail persons with multimorbidity.[622][623] Similarly, multidisciplinary palliative care programs for adults with advanced chronic illness can improve patient and caregiver outcomes, reduce health service utilization, and increase the chances of dying at home.[624][627]


172. We recommend that a HF specialist or clinic should have the capacity to accept referrals, transition of care, or arrange for transfer to a tertiary care centre within the recommended CCS benchmarks (Strong Recommendation; Very Low-Quality Evidence).

173. We recommend that specialized outpatient HF clinics or disease management programs provide access to an interprofessional team ideally including a physician, a nurse, and a pharmacist with experience and expertise in HF (Strong Recommendation; High-Quality Evidence).

174. We recommend that all patients with recurrent HF hospitalizations, irrespective of age, multimorbidity, or frailty, should be referred to a HF disease management program (Strong Recommendation; High-Quality Evidence).

Practical Tip

Patients with HF should have regular follow-up assessments, with their intensity and frequency tailored according to individual risk and stability (Table 41).

Follow-up assessments should include symptoms, function, quality of life, physical examination, medication reconciliation and review, and a review of updated laboratory results and diagnostic test results (Fig. 12). Emerging needs, such as disability, other health concerns (Table 42), caregiver burden, and advance care plans should be reviewed as well.

Follow-up methods might include telemonitoring, structured telephone support, or home visits, all of which have variable evidence to support this and should be localized.[615],[616]

HF management includes coaching patients and informal caregivers on self-care skills, through experiential learning, practice, and support.[617],[618]

Self-care includes knowledge, skills, and confidence about HF treatments, exercise, dietary measures, symptom-, and weight-monitoring. It also includes an action plan to address exacerbations early and determine if actions were helpful to circumvent further deterioration. This plan should facilitate rapid access, either in person, by phone, or other modes of communication or technology, to HF clinic staff for assistance.[619]

Home-based HF management, which can include hospital-at-home care, might be beneficial for highly selected patients.[620],[621]

8.3 Systems-level considerations

Integration is a system-wide process of combining social and health services to meet the needs of the patients with chronic disease through alignment of financial and administrative modalities, with the clinical practices of multidisciplinary care teams.[628][630] Care coordination is integral to the Chronic Disease Management model, which has been recommended as the preferred model for care delivery for CVD by the Canadian Heart Health Strategy Action Plan.[631] Patient assessments throughout their journey with HF should continuously be linked with updated management plans, through seamless communication between the patient, primary to tertiary care, palliative care, and with community care resources.[632] Clinical trials of community-based integrated systems of care for frail seniors have shown better care quality, coordination, and continuity, better health outcomes, and equal or reduced overall costs.[632][636] Further, integration of multidisciplinary palliative care services in the care of patients with advancing HF can reduce symptom burden and health system utilization.[637][639] Features of an integrated care model for patients with HF are described in Table 43.[640]

Proper execution of care transitions from hospital to the community is particularly important, because patients with HF have high rates of readmission. Older patients with multimorbidity, frailty, and previous HF hospitalizations are at increased risk for readmission.[641] Important elements of successful transitional care programs have been identified and should be considered on the basis of local resources, which are outlined in section 8.3 of the Supplementary Material.[642][648]


175. We recommend that care for patients with HF be organized within an integrated system of health care delivery in which patient information and care plans are accessible to collaborating practitioners across the continuum of care (Strong Recommendation; Moderate-Quality Evidence).


559. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511-44.

560. Herr JK, Salyer J, Lyon DE, et al. Heart failure symptom relationships: a systematic review. J Cardiovasc Nurs 2014;29:416-22.

561. National Clinical Guideline C. National Institute for Health and Clinical Excellence: Guidance. Delirium: Diagnosis, Prevention and Management. London: Royal College of Physicians (UK) National Clinical Guideline Centre – Acute and Chronic Conditions, 2010.

562. Zavertnik JE. Self-care in older adults with heart failure: an integrative review. Clin Nurse Spec 2014;28:19-32.

563. Currie K, Rideout A, Lindsay G, Harkness K. The association between mild cognitive impairment and self-care in adults with chronic heart failure: a systematic review and narrative synthesis. J Cardiovasc Nurs 2015;30:382-93.

564. Heckman GA, Tannenbaum C, Costa AP, Harkness K, McKelvie RS. The journey of the frail older adult with heart failure: implications for management and health care systems. Rev Clin Gerontol 2014;24: 269-89.

565. Leto L, Feola M. Cognitive impairment in heart failure patients. J Geriatr Cardiol 2014;11:316-28.

566. Sokoreli I, de Vries JJ, Pauws SC, Steyerberg EW. Depression and anxiety as predictors of mortality among heart failure patients: systematic review and meta-analysis. Heart Fail Rev 2016;21:49-63.

567. Stewart S, Riegel B, Boyd C, et al. Establishing a pragmatic framework to optimise health outcomes in heart failure and multimorbidity (ARISE-HF): a multidisciplinary position statement. Int J Cardiol 2016;212:1-10.

568. Jha SR, Ha HS, Hickman LD, et al. Frailty in advanced heart failure: a systematic review. Heart Fail Rev 2015;20:553-60.

569. Svanstrom H, Pasternak B, Melbye M, Hviid A. Use of different types of angiotensin converting enzyme inhibitors and mortality in systolic heart failure. Int J Cardiol 2015;182:90-6.

570. Vorilhon C, Chenaf C, Mulliez A, et al. Heart failure prognosis and management in over-80-year-old patients: data from a French national observational retrospective cohort. Eur J Clin Pharmacol 2015;71: 251-60.

571. Forman DE, Ahmed A, Fleg JL. Heart failure in very old adults. Curr Heart Fail Rep 2013;10:387-400.

572. Mujib M, Patel K, Fonarow GC, et al. Angiotensin-converting enzyme inhibitors and outcomes in heart failure and preserved ejection fraction. Am J Med 2013;126:401-10.

573. Scherer M, Dungen HD, Inkrot S, et al. Determinants of change in quality of life in the Cardiac Insufficiency Bisoprolol Study in Elderly (CIBIS-ELD). Eur J Intern Med 2013;24:333-8.

574. Man JP, Jugdutt BI. Systolic heart failure in the elderly: optimizing medical management. Heart Fail Rev 2012;17:563-71.

575. Savioli Neto F, Magalhaes HM, Batlouni M, Piegas LS. ACE inhibitors and plasma B-type natriuretic peptide levels in elderly patients with heart failure. Arq Bras Cardiol 2009;92:320-6. 36-43, 49-56.

576. Dekleva M, Dungen HD, Gelbrich G, et al. Beta blockers therapy is associated with improved left ventricular systolic function and sustained exercise capacity in elderly patients with heart failure. CIBIS-ELD substudy. Aging Clin Exp Res 2012;24:675-81.

577. Tannenbaum C, Johnell K. Managing therapeutic competition in patients with heart failure, lower urinary tract symptoms and incontinence. Drugs Aging 2014;31:93-101.

578. Chisholm P, Anpalahan M. Orthostatic hypotension – pathophysiology, assessment, treatment, and the paradox of supine hypertension – a review. Intern Med J 2017;47:370-9.

579. Gorelik O, Feldman L, Cohen N. Heart failure and orthostatic hypotension. Heart Fail Rev 2016;21:529-38.

580. Muscedere J, Andrew MK, Bagshaw SM, et al. Screening for frailty in Canada’s health care system: a time for action. Can J Aging 2016;35: 1-17.

581. Heckman GA, Braceland B. Integrating frailty assessment into cardiovascular decision-making. Can J Cardiol 2016;32:139-41.

582. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing 2006;35:526-9.

583. Rockwood K, Andrew M, Mitnitski A. A comparison of two approaches to measuring frailty in elderly people. J Gerontol A Biol Sci Med Sci 2007;62:738-43.

584. Heckman GA, Gray L, Hirdes J. Addressing health care needs for frail seniors in Canada: the role of interRAI instruments. CGS J CME 2013;3:8-16.

585. McIlvennan CK, Allen LA. Palliative care in patients with heart failure. BMJ 2016;353:i1010.

586. Doherty LC, Fitzsimons D, McIlfatrick SJ. Carers’ needs in advanced heart failure: a systematic narrative review. Eur J Cardiovasc Nurs 2016;15:203-12.

587. Fendler TJ, Swetz KM, Allen LA. Team-based palliative and end-of-life care for heart failure. Heart Fail Clin 2015;11:479-98.

588. Whellan DJ, Goodlin SJ, Dickinson MG, et al. End-of-life care in patients with heart failure. J Card Fail 2014;20:121-34.

589. Lemond L, Allen LA. Palliative care and hospice in advanced heart failure. Prog Cardiovasc Dis 2011;54:168-78.

590. Chaudhry SP, Stewart GC. Advanced heart failure: prevalence, natural history, and prognosis. Heart Fail Clin 2016;12:323-33.

591. Jaarsma T, Beattie JM, Ryder M, et al. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2009;11:433-43.

592. McKelvie RS, Moe GW, Cheung A, et al. The 2011 Canadian Cardiovascular Society heart failure management guidelines update: focus on sleep apnea, renal dysfunction, mechanical circulatory support, and palliative care. Can J Cardiol 2011;27:319-38.

593. Whittingham K, Barnes S, Gardiner C. Tools to measure quality of life and carer burden in informal carers of heart failure patients: a narrative review. Palliat Med 2013;27:596-607.

594. MacIver J, Wentlandt K, Ross HJ. Measuring quality of life in advanced heart failure. Curr Opin Support Palliat Care 2017;11:12-6.

595. Rajati F, Feizi A, Tavakol K, et al. Comparative evaluation of healthrelated quality of life questionnaires in patients with heart failure undergoing cardiac rehabilitation: a psychometric study. Arch Phys Med Rehabil 2016;97:1953-62.

596. Hofer S, Lim L, Guyatt G, Oldridge N. The MacNew Heart Disease health-related quality of life instrument: a summary. Health Qual Life Outcomes 2004;2:3.

597. Kelkar AA, Spertus J, Pang P, et al. Utility of patient-reported outcome instruments in heart failure. JACC Heart Fail 2016;4:165-75.

598. Rector TS, Kubo SH, Cohn JN. Patients’ self-assessment of their congestive heart failure. Part 2: content, reliability and validity of a new measure, the Minnesota Living with Heart Failure Questionnaire. Heart Fail 1987;3:198-209.

599. Prior JA, Jordan KP, Kadam UT. Variations in patient-reported physical health between cardiac and musculoskeletal diseases: systematic review and meta-analysis of population-based studies. Health Qual Life Outcomes 2015;13:71.

600. Hui D, Bruera E. The Edmonton Symptom Assessment System 25 years later: past, present and future developments. J Pain Symptom Manage 2017;53:630-43.

601. Harkness KI, Tranmer JE. Measurement of the caregiving experience in caregivers of persons living with heart failure: a review of current instruments. J Card Fail 2007;13:577-87.

602. Makdessi A, Harkness K, Luttik ML, McKelvie RS. The Dutch Objective Burden Inventory: validity and reliability in a Canadian population of caregivers for people with heart failure. Eur J Cardiovasc Nurs 2011;10:234-40.

603. Elmstahl S, Malmberg B, Annerstedt L. Caregiver’s burden of patients 3 years after stroke assessed by a novel caregiver burden scale. Arch Phys Med Rehabil 1996;77:177-82.

604. Al-Rawashdeh SY, Lennie TA, Chung ML. Psychometrics of the Zarit Burden Interview in caregivers of patients with heart failure. J Cardiovasc Nurs 2016;31:E21-8.

605. Gadoud A, Jenkins SM, Hogg KJ. Palliative care for people with heart failure: summary of current evidence and future direction. Palliat Med 2013;27:822-8.

606. Hochgerner M, Fruhwald FM, Strohscheer I. Opioids for symptomatic therapy of dyspnoea in patients with advanced chronic heart failureeis there evidence? Wien Med Wochenschr 2009;159:577-82.

607. Lowey SE, Powers BA, Xue Y. Short of breath and dying: state of the science on opioid agents for the palliation of refractory dyspnea in older adults. J Gerontol Nurs 2013;39:43-52.

608. Beattie JM, Johnson MJ. Subcutaneous furosemide in advanced heart failure: has clinical practice run ahead of the evidence base? BMJ Support Palliat Care 2012;2:5-6.

609. McClung JA. End-of-life care in the treatment of advanced heart failure in the elderly. Cardiol Rev 2013;21:9-15.

610. Ghashghaei R, Yousefzai R, Adler E. Palliative care in heart failure. Prog Cardiovasc Dis 2016;58:455-60.

611. Hauptman PJ, Mikolajczak P, George A, et al. Chronic inotropic therapy in end-stage heart failure. Am Heart J 2006;152:1096.e1-8.

612. Simon ST, Higginson IJ, Booth S, et al. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev 2016;10:CD007354.

613. Abernethy AP, Currow DC, Frith P, et al. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ 2003;327:523-8.

614. Clemens KE, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care Cancer 2009;17:367-77.

615. Inglis SC, Clark RA, McAlister FA, Stewart S, Cleland JG. Which components of heart failure programmes are effective? A systematic review and meta-analysis of the outcomes of structured telephone support or telemonitoring as the primary component of chronic heart failure management in 8323 patients: Abridged Cochrane Review. Eur J Heart Fail 2011;13:1028-40.

616. Inglis SC, Clark RA, Dierckx R, Prieto-Merino D, Cleland JG. Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database Syst Rev 2015:CD007228.

617. Clark AM, Wiens KS, Banner D, et al. A systematic review of the main mechanisms of heart failure disease management interventions. Heart 2016;102:707-11.

618. Clark AM, Spaling M, Harkness K, et al. Determinants of effective heart failure self-care: a systematic review of patients’ and caregivers’ perceptions. Heart 2014;100:716-21.

619. Riegel B, Moser DK, Anker SD, et al. State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association. Circulation 2009;120:1141-63.

620. Fergenbaum J, Bermingham S, Krahn M, Alter D, Demers C. Care in the home for the management of chronic heart failure: systematic review and cost-effectiveness analysis. J Cardiovasc Nurs 2015;30:S44-51.

621. Qaddoura A, Yazdan-Ashoori P, Kabali C, et al. Efficacy of hospital at home in patients with heart failure: a systematic review and metaanalysis. PLoS One 2015;10:e0129282.

622. Wijeysundera HC, Trubiani G, Wang X, et al. A population-based study to evaluate the effectiveness of multidisciplinary heart failure clinics and identify important service components. Circ Heart Fail 2013;6:68-75.

623. Pulignano G, Del Sindaco D, Di Lenarda A, et al. Usefulness of frailty profile for targeting older heart failure patients in disease management programs: a cost-effectiveness, pilot study. J Cardiovasc Med (Hagerstown) 2010;11:739-47.

624. Willey RM. Managing heart failure: a critical appraisal of the literature. J Cardiovasc Nurs 2012;27:403-17.

625. Gomes B, Calanzani N, Curiale V, McCrone P, Higginson IJ. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev 2013:CD007760.

626. Singer AE, Goebel JR, Kim YS, et al. Populations and interventions for palliative and end-of-life care: a systematic review. J Palliat Med 2016;19:995-1008.

627. Diop MS, Rudolph JL, Zimmerman KM, Richter MA, Skarf LM. Palliative care interventions for patients with heart failure: a systematic review and meta-analysis. J Palliat Med 2017;20:84-92.

628. Hoffmarcher MM, Oxley H, Rusticelli E. Improved Health System Performance through Better Care Coordination. Health Working Paper No. 30. Paris: OECD Publishing, 2007.

629. Grone O, Garcia-Barbero M. WHO European Office for Integrated Health Care Services. Integrated care: a position paper of the WHO European Office for Integrated Health Care Services. Int J Integr Care 2001;1:e21.

630. Vedel I, Monette M, Beland F, Monette J, Bergman H. Ten years of integrated care: backwards and forwards. The case of the province of Quebec, Canada. Int J Integr Care 2011;11(spec ed):e004.

631. Smith ER. The Canadian heart health strategy and action plan. Can J Cardiol 2009;25:451-2.

632. McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Vol. 7. Rockville, MD: Care Coordination, 2007.

633. Mackie S, Darvill A. Factors enabling implementation of integrated health and social care: a systematic review. Br J Community Nurs 2016;21:82-7.

634. Veras RP, Caldas CP, Motta LB, et al. Integration and continuity of care in health care network models for frail older adults. Rev Saude Publica 2014;48:357-65.

635. Johri M, Beland F, Bergman H. International experiments in integrated care for the elderly: a synthesis of the evidence. Int J Geriatr Psychiatry 2003;18:222-35.

636. Del Sindaco D, Pulignano G, Minardi G, et al. Two-year outcome of a prospective, controlled study of a disease management programme for elderly patients with heart failure. J Cardiovasc Med (Hagerstown) 2007;8:324-9.

637. Brannstrom M, Boman K. Effects of person-centred and integrated chronic heart failure and palliative home care. PREFER: a randomized controlled study. Eur J Heart Fail 2014;16:1142-51.

638. Sidebottom AC, Jorgenson A, Richards H, Kirven J, Sillah A. Inpatient palliative care for patients with acute heart failure: outcomes from a randomized trial. J Palliat Med 2015;18:134-42.

639. Ryder M, Beattie JM, O’Hanlon R, McDonald K. Multidsciplinary heart failure management and end of life care. Curr Opin Support Palliat Care 2011;5:317-21.

640. McKelvie RS, Heckman GA, Blais C, et al. Canadian Cardiovascular Society Quality Indicators for Heart Failure. Can J Cardiol 2016;32: 1038.e5-9.

641. Saito M, Negishi K, Marwick TH. Meta-analysis of risks for short-term readmission in patients with heart failure. Am J Cardiol 2016;117: 626-32.

642. Albert NM. A systematic review of transitional-care strategies to reduce rehospitalization in patients with heart failure. Heart Lung 2016;45: 100-13.

643. Vedel I, Khanassov V. Transitional care for patients with congestive heart failure: a systematic review and meta-analysis. Ann Fam Med 2015;13:562-71.

644. Feltner C, Jones CD, Cene CW, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med 2014;160:774-84.

645. Lambrinou E, Kalogirou F, Lamnisos D, Sourtzi P. Effectiveness of heart failure management programmes with nurse-led discharge planning in reducing re-admissions: a systematic review and meta-analysis. Int J Nurs Stud 2012;49:610-24.

646. Phillips CO, Wright SM, Kern DE, et al. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA 2004;291:1358-67.

647. Bryant-Lukosius D, Carter N, Reid K, et al. The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review. J Eval Clin Pract 2015;21:763-81.

648. Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 2009;301:603-18.

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