Post-Hospitalization Transition Phase after an Episode of Acute Congestive Heart Failure Program (p.e.a.c.h. Program). Adoption of a Remote Medicine System in the Post-Hospitalization Transition Phase after an Episode of Acute Congestive Heart Failure (tele p.e.a.c.h.) Creation of an Organizational Model based on Telemedicine with Contextual Collection of Clinical, Laboratory, Ultrasound Parameters and their Correlation with Short-Medium Term Outcomes (Data p.e.a.c.h)

The transition phase after hospital discharge for acute heart failure must be governed to achieve the best guideline-directed medical therapy (GDMT) and to avoid major outcomes. For this reason, we planned a 30-day follow up with tele visit and with bio humoral and heart-lungs ultrasound parameters. The KCCQ score, a clinical monitoring form, a HLPOCUs diagram and a database were used to titrate the drugs and to record a prognostic score. Four weeks after discharge the percentage of patients in GDMT had increased, the clinical signs of heart failure had disappeared, the echo graphic parameters of systolic/diastolic function and pulmonary congestion were significantly improved, the blood tests did better. The quality of life was also significantly improved as evidenced by the KCCQ score. Furthermore, the number of Emergency Department visits and hospitalizations for heart failure in the short follow up were reduced. In conclusion, post-hospitalization during the transition phase and with the help of tele nursing made it possible to optimize heart failure therapy, improve prognostic parameters and short-term outcomes.