Better Effectiveness After Transition - Heart Failure

Inclusion Criteria:

- patients hospitalized at any of the six medical centers who are being actively
treated for heart failure.

Exclusion Criteria:

- patients who have previously received a transplant, are being evaluated for a
transplant, or who are on the wait list for a transplant,

- patients who are enrolled or enrolling in hospice, or are expected to expire shortly
after discharge,

- patients with dementia,

- patients who are admitted from a skilled nursing facility (SNF), or who we anticipate
will be discharged to a long term stay in a SNF,

- patients who do not have a working land line phone or reliable cell service,

- patients on chronic dialysis,

- patients who cannot identify a usual source of care (free clinic is acceptable) and
who will not be assigned a provider upon discharge,

- patients with the following cardiovascular conditions: patients with valvular
disorders requiring surgical intervention (except for those with incidental valvular
disease, who will be included), acute myocardial infarction (except for those with
demand ischemia, who will be included), percutaneous coronary intervention

- patients expected to enroll in hospice or expire after discharge,

- patients who are unable to use the intervention equipment (e.g., unable to stand on
the weight scale), or who are otherwise unable to comply with the intervention