Shared and standardized information system accessible from any point in the care network.

Shared care plan with clearly defined patient-centered goals of care, and mutually understood and agreed-upon provider (formal and informal) responsibilities.

An organizational framework clearly specifying the linkages between constituents of the care network and community-based services.

Clearly defined protocols to facilitate seamless transitions and navigation for patients and providers between levels and sites of care, and which are anchored in primary care.

In addition to clinical staff, additional resources should include

• Program support a coordination, commensurate with its size and scope;
• Access to Continuing Medical Education support knowledge translation.

Standardized risk stratification criteria to ensure timely referral and access to appropriate care;

Access to other services:

• Specialists: cardiology, geriatrics, psychiatry, internal medicine, rehabilitation;
• Palliative care, spiritual care; and
• Home care and community support services.

Measurement and submission of mandated quality measures to appropriate authority;

Measurement of Quality Indicators, as defined by the Canadian Cardiovascular Society Quality Indicators Working group for Heart Failure.