Better Effectiveness After Transition - 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