Team-Based Transitions of Care in Heart Failure

Transitions of care are a highly vulnerable period for patients living with heart failure. With the focus on increasing efficiencies and cost-effectiveness of the health care delivery system, clinicians are looking at models that have proved their effectiveness at improving the quality of care in this population. In this article, the changes in health care, frameworks for team-based approaches to care, and models of transitional care patient management that have been effective in other patient populations are examined.