Post-Discharge Heart Failure Management through Mobile Integrated Health Services
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By
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Meghan Reading Turchioe
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Melani Ellison
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Leah Shafran Topaz
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Christina McGinnis
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Jacky Choi
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Yihong Zhao
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Stacey Dai
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Parag Goyal
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Rohit Mukherjee
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Erik Blutinger
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Roland C. Merchant
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Brock Daniels
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Ruth Masterson Creber
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August 21, 2026
Clinical Scorecard: Post-Discharge Heart Failure Management through Mobile Integrated Health Services
At a Glance
| Category | Detail |
|---|
| Condition | Heart Failure Management |
| Key Mechanisms | Mobile Integrated Health (MIH) delivery model providing patient-centered, nonemergency services in home or community settings. |
| Target Population | Patients discharged following hospitalization for heart failure. |
| Care Setting | Community and home-based health care delivery. |
Key Highlights
- MIH programs may reduce emergency department transports and 30-day hospital readmissions.
- High patient and clinician satisfaction reported with MIH services.
- Substantial variation exists among MIH programs in clinical protocols and follow-up.
- Evaluation of MIH effectiveness is guided by the RE-AIM framework.
- Qualitative analysis involved interviews with patients and health care professionals.
Guideline-Based Recommendations
Diagnosis
Management
Monitoring & Follow-up
Risks
Patient & Prescribing Data
Adults with heart failure discharged from hospitalization.
MIH programs incorporate telemedicine and interdisciplinary teams.
Clinical Best Practices
- Utilize interdisciplinary teams for MIH implementation.
- Incorporate telemedicine in post-discharge care.
- Standardize evaluation of MIH program effectiveness.
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