A dedicated multidisciplinary program of care for patients with chronic heart failure following hospitalisation. This involves:

• patient education and counselling
• promoting self-care behaviours
• intensive follow-up to proactively detect and address clinical problems
• applying evidence-based medications and improving adherence
• fluid and electrolyte management and physical activity programs
• developing coping strategies
• maximising psychological and social parameters

Priority should be given to face-to-face management of patients, but remote management assisted by structured telephone support and telemonitoring should be considered for patients with limited access.