Home-Based Care Management for Patients Post-Heart Failure Index Hospitalization: A Comprehensive Review

Heart failure (HF) is a clinical syndrome characterized by cardiac structural or functional abnormalities, often leading to hospitalization. Common causes of HF include ischemic and rheumatic heart diseases, with a male predominance. Diagnosis relies on clinical evaluation, electrocardiogram, chest X-ray, and biomarkers like N-terminal pro-B-type natriuretic peptide. Left ventricular ejection fraction classifies HF into reduced, mildly reduced, preserved, and improved ejection fraction. Guideline-directed medical therapy includes angiotensin-converting enzyme inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors. Surgical interventions, such as coronary artery bypass grafting, device implantation, heart transplantation, and percutaneous coronary intervention, are also employed. Emphasis on multidisciplinary management, patient education, and lifestyle changes improves adherence and reduces hospital readmission rates. Post-hospitalization management increasingly relies on home-based care, achieving outcomes equivalent to clinic-based programs, including improved quality of life, lower mortality, and reduced healthcare costs. The integration of telehealth and mobile applications has expanded remote monitoring and patient engagement. However, challenges such as limited infrastructure, resource constraints, and the lack of standardized protocols hinder optimal implementation. This review highlights the essential role of home-based care for patients with HF post-hospitalization and the need for a comprehensive workbook with a care pathway that provides information on medications, follow-up, and dietary guidelines. The workbook also equips the cardiovascular care team with the skills and knowledge needed for high-quality, patient-centered, home-based care.