Team-Based Transitions of Care in Heart Failure

With the implementation of the Patient Protection and Affordable Care Act, the requisite for health care systems to build team-based transitional care programs is clear. The clinical course for patients with HF is complicated and progressive, which leads to frequent acute care hospitalization and higher mortality. These patients uniquely benefit from transitions of care programs that encourage a coordinated, multidisciplinary teambased approach to care. Evidence of the benefit of this approach to care is mounting. Research and advocacy efforts need to continue to facilitate the team-based approach to transitions and improve the quality of care.