Heart failure (HF) is a growing public health problem. The management of HF is usually multi-disciplinary and should comprise the cooperation of all groups of individuals involved in the care like clinicians, cardiologists, general practitioners, internists, nurses, relatives and patients. There is an ongoing debate with regard to monitoring and the optimal level and intensity of care for which kind of patients. Based on our experience with the recently established HF network HerzMobil Tirol, we developed a concept how to combine mHealth-based telemonitoring and disease management programs. The collaborative HF management concept timely and efficiently closes the feedback loop between patients and care providers and allows for continuity of care. The aim is to gradually adjust intensity of care according to the patients' level of disease severity and risk of readmission after hospital discharge along the overall trajectory of illness. Next steps will be to investigate how to define shared decision making, rights, duties, responsibilities and liabilities of the individual stakeholders as well as to analyze business models for reimbursement.
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