Remote patient monitoring support: Review of transmitted weight, blood pressure, pulse, and other ordered data based on the program design, with threshold-based escalation.
Heart Failure Care Management That Extends Beyond the Office Visit
Support earlier identification of clinical risk through coordinated disease management, medication review, remote monitoring, and post-discharge care.
Close the Gaps That Put Heart Failure Patients at Risk
Heart failure requires far more than periodic office visits. Changes in weight, blood pressure, symptoms, medication use, diet, and access to follow-up care can signal increasing risk between appointments. A recent hospitalization makes the need for timely, coordinated support even more urgent.
PharmD Live’s Heart Failure Care Management Program helps cardiology practices, primary care organizations, ACOs, IDNs, health systems, and payers extend care into the weeks and months between visits.
Our multidisciplinary clinical team supports the patient’s existing providers through condition-specific monitoring, patient education, clinical pharmacist-led medication review, care-transition follow-up, and assessment of the social barriers that can undermine heart failure management.
The PharmD Live Three-Part Care Model
Heart Failure Disease Management
The team reinforces the provider-established care plan; monitors reported symptoms, weight, blood pressure, and other relevant information; supports self-management education; identifies care gaps; and escalates concerning findings according to agreed clinical protocols.
Patients receive practical education on recognizing worsening symptoms, following sodium and fluid recommendations provided by their clinician, using monitoring equipment, and knowing when to contact the care team or seek urgent evaluation.
Clinical Pharmacist-Led Medication Management
Heart failure patients often manage complex regimens alongside medications for diabetes, kidney disease, hypertension, atrial fibrillation, and other conditions. PharmD Live’s clinical pharmacists:
Reconcile medications following hospitalization and during ongoing care.
Review the regimen for duplication, interactions, adherence concerns, side effects, and dose appropriateness.
Assess the medication list against current guideline-directed treatment considerations and available clinical information.
Identify barriers such as cost, confusion, refill gaps, or treatment burden.
Send informed, guideline-driven recommendations to the prescriber.
Social Determinants of Health Support
Heart failure management may be disrupted by medication affordability, limited access to appropriate food, transportation problems, health literacy, unstable housing, difficulty using monitoring devices, or inadequate caregiver support. The team identifies relevant barriers, communicates them to the care team, and helps connect patients with appropriate resources when available.
Program Capabilities
Post-discharge outreach: Timely contact after an eligible transition to reconcile medications, confirm follow-up plans, identify gaps, and support the 30-day transition period.
Longitudinal care management: Ongoing care-plan support and patient engagement between cardiology and primary care visits.
Medication adherence support: Identification of refill, affordability, side-effect, complexity, and understanding barriers.
Care coordination: Communication of relevant findings and recommendations to the patient’s authorized treating clinicians.
Preventive and comorbidity support: Coordination around diabetes, kidney disease, hypertension, behavioral health, vaccination, and other needs influencing heart failure outcomes.
Outcomes the Program Is Designed to Support
Earlier recognition and escalation of worsening symptoms
Safer transitions from hospital to home
More complete medication reconciliation
Improved adherence and medication understanding
Greater alignment with the prescriber’s treatment plan
Fewer potentially avoidable emergency visits and readmissions
Improved patient confidence and engagement
Better visibility into social and access barriers
Stronger value-based care and population health performance
Designed for High-Risk Populations and Value-Based Organizations
The program is appropriate for cardiology and primary care practices, ACOs, IDNs, hospitals, health systems, and health plans seeking a scalable way to support heart failure patients between visits and after discharge.
For ACOs and IDNs, the program can be aligned with high-risk patient identification, utilization-reduction priorities, care-transition workflows, and quality-improvement strategies. For payers, the model supports medication adherence, member engagement, chronic disease control, and avoidance of unnecessary acute care.
Frequently Asked Questions
How does the program help reduce avoidable readmissions?
The program combines timely post-discharge contact, medication reconciliation, symptom and monitoring review, patient education, and escalation of concerning findings to the treating team. These activities are intended to identify gaps and clinical risk before they contribute to avoidable deterioration.
Does PharmD Live change heart failure medications?
No. Clinical pharmacists review the medication regimen and send guideline-driven recommendations to the prescriber. The prescriber makes all prescribing and medication-adjustment decisions.
Can the program work with the patient’s cardiologist and primary care clinician?
Yes. PharmD Live functions as an extension of the existing care team. The implementation process defines how findings, recommendations, and escalations are communicated to the appropriate clinicians.
Does every patient require remote monitoring?
No. The appropriate services and monitoring cadence depend on patient eligibility, clinical risk, provider orders, program design, and the patient’s ability to participate.
Extend Heart Failure Care Into the Days That Matter Most
Give your clinicians greater support between visits and after discharge—without building an entirely new care-management workforce.