learning needs, continuity of care and care coordination
across settings, and the use of expert nurses to deliver and
manage clinical services to high risk patient groups; and (3)
APN implementation of an evidence-based protocol, guided
by national heart failure guidelines18,19 and designed
specifically for this patient group and their caregivers with
a unique focus on comprehensive management of needs and
therapies associated with an acute episode of heart failure
complicated by multiple comorbid conditions