• Andreas Von der Heidt, Elske Ammenwerth, Karl Bauer, Bettina Fetz, Thomas Fluckinger, Andrea Gassner, Willhelm Grander, Walter Gritsch, Immaculata Haffner, Gudrun Henle-Talirz, Stefan Hoschek, Stephan Huter, Peter Kastner, Susanne Krestan, Peter Kufner, Robert Modre-Osprian, Josef Noebl, Momen Radi, Clemens Raffeiner, Stefan Welte, Andreas Wiseman, and Gerhard Poelzl.
• Clinical Division of Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
• Wien. Klin. Wochenschr. 2014 Nov 1; 126 (21-22): 734-41.

AbstractHeart failure (HF) is approaching epidemic proportions worldwide and is the leading cause of hospitalization in the elderly population. High rates of readmission contribute substantially to excessive health care costs and highlight the fragmented nature of care available to HF patients. Disease management programs (DMPs) have been implemented to improve health outcomes, patient satisfaction, and quality of life, and to reduce health care costs. Telemonitoring systems appear to be effective in the vulnerable phase after discharge from hospital to prevent early readmissions. DMPs that emphasize comprehensive patient education and guideline-adjusted therapy have shown great promise to result in beneficial long-term effects. It can be speculated that combining core elements of the aforementioned programs may substantially improve long-term cost-effectiveness of patient management.We introduce a collaborative post-discharge HF disease management program (HerzMobil Tirol network) that incorporates physician-controlled telemonitoring and nurse-led care in a multidisciplinary network approach.

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