A Study of a Technology-enabled Disease Management Program to Reduce Hospitalizations for Heart Failure

Inclusion criteria

• Patients age ≥ 18 with a primary care provider or specialist that is participating within the Collaborative Health ACO.
• Patient able to consent
• A diagnosis of heart failure with at least one of the following risk factors:

• Hospitalization for heart failure within the prior year
• NYHA class III-IV symptoms
• Most recent BNP ≥ 300 pg/mL (or Nt-proBNP ≥ 600 pg/mL) as long as within 90 days prior to enrollment

Exclusion criteria

• Acute myocardial infarction, PCI or CABG within 30 days before enrollment
• Planned revascularization procedures, cardiac mechanical support implantation, cardiac transplantation, or other cardiac surgery within 30 days following study randomization.
• Illness other than heart failure deemed the principal limitation to life expectancy or principal cause of disability
• Severe angina as the principal cause of limitation
• Uncorrected valvular disease, except where valvular regurgitation was considered to be secondary to severe left ventricular dilation, or where surgical correction is deemed excessively risky or declined by the patient.
• Moderate to severe dementia such that unable to participate in disease management program
• Severe visual or auditory disability such that unable to participate in disease management program
• Hospice care
• Listed for heart transplantation
• No access to a working telephone
• Homeless or no stable home environment
• Not speaking a language in which the educational documents have been translated