Introduction
Heart failure affects millions worldwide and often leads to repeated hospitalizations, imposing significant burdens on patients and healthcare systems. Effective management after hospital discharge is critical to improve patient health, reduce readmissions, and enhance quality of life. Two approaches have gained attention to support patients in this vulnerable post-acute period: Transitions of Care Coordination (TOCC) and Mobile Integrated Health (MIH).
TOCC generally involves a nurse-led follow-up phone call shortly after discharge to ensure patients understand their care plan, manage medications, and receive timely support. MIH expands on this model by adding in-person home visits from community paramedics and telehealth consultations with emergency medicine physicians, aiming to provide more continuous, comprehensive support.
