Recommendation 172: We recommend that a HF specialist or clinic should have the capacity to accept referrals, transition of care or arrange for transfer to a tertiary care centre within the recommended CCS benchmarks (Strong Recommendation, Very Low Quality Evidence).

Recommendation 173: We recommend that specialized outpatient HF clinics or disease management programs provide access to an interprofessional team ideally including a physician, a nurse, and a pharmacist with experience and expertise in HF (Strong Recommendation, High Quality Evidence).

Recommendation 174: We recommend that all patients with recurrent HF hospitalizations, irrespective of age, multimorbidity, or frailty, should be referred to a HF disease management program (Strong Recommendation, High Quality Evidence).

• Patients with HF should have regular follow-up assessments, with their intensity and frequency of tailored according to individual risk and stability (Table 41).
• Follow-up assessments should include symptoms, function, quality of life, physical examination, medication reconciliation and review, and a review of updated laboratory results and diagnostic test results (Figure 12). Emerging needs, such as disability, other health concerns (Table 42), caregiver burden, and advance care plans should be reviewed as well.
• Follow-up methods may include telemonitoring, structured telephone support, or home visits, all of which have variable evidence to support this and should be localized.
• HF management includes coaching patients and informal caregivers on self-care skills, through experiential learning, practice and support.
• Self-care includes knowledge, skills and confidence about HF treatments, exercise, dietary measures, symptom and weight monitoring. It also includes an action plan to address exacerbations early and determine if actions were helpful to circumvent further deterioration. This plan should facilitate rapid access, either in person, by phone, or other modes of communication or technology, to HF clinic staff for assistance.
• Home-based HF management, which can include Hospital-at-Home care, may be beneficial for highly selected patients.