Hospital-to-community care pathways for patients with heart failure, an inter-society consensus document

Heart failure (HF) remains one of the most prevalent and burdensome chronic conditions worldwide, with rising incidence and poor prognosis despite major therapeutic advances. Effective management requires a comprehensive, multidisciplinary approach that ensures diagnostic accuracy, therapeutic optimization, and continuity of care from hospital to community settings. This consensus document outlines an integrated model for HF care in Italy, developed to improve patient outcomes and resource efficiency. HF should be diagnosed and phenotyped through clinical evaluation, electrocardiography, echocardiography, biomarkers, and, when indicated, advanced imaging. Guideline-directed medical therapy, including sodium-glucose cotransporter-2 inhibitors, angiotensin receptor-neprilysin inhibitors, β-blockers, and mineralocorticoid receptor antagonists, remains the cornerstone of treatment across the ejection-fraction spectrum. Device therapy, cardiac rehabilitation, and iron supplementation complement pharmacological management. Telemedicine and remote monitoring enable early detection of clinical deterioration and strengthen hospital-community integration, while multidisciplinary HF clinics coordinate pharmacological care, rehabilitation, and patient education. Structured training of healthcare professionals and caregivers, along with therapeutic education programs, enhances adherence, empowers patients, and promotes self-management. Community-based associations further support cardiovascular prevention through educational and screening initiatives. The integration of hospital, community, and digital health resources, combined with continuous professional training and patient empowerment, represents a sustainable and effective model to improve survival, reduce hospitalizations, and enhance quality of life for patients with HF.