Table 4.

Reducing HF Hospitalizations and Optimizing the Care Continuum

1.	Train and incorporate lay-person navigators into care processes.
2.	Enable all health care providers to practice at the top of their license, including nurses, pharmacists, nurse practitioners, and physician assistants and utilize their expertise for processes such as medication reconciliation, patient education, patient engagement and virtual visits.
3.	Develop and test strategies to increase patient and caretaker engagement.
4.	Define and test “distance-health” methodologies such as virtual visits. Realign provision of care and the payments for care to allow for more flexible effective care models that utilize remote monitoring technology.
5.	Develop population health interventions such as system alerts for missed prescription refills. Systems with the capability to notify pharmacists, patients, or providers about missed prescription refills create an opportunity to engage patients in a conversation about what barriers they might be facing.
6.	Develop and test strategies to incentivize patients to take responsibility for self-management.