Examples of what has been done

A disease management programme focused on improving transitions between specialist and primary care


HeartNetCare-HF is an evidence-based disease management program involving specialised nurses, GPs and cardiologists aimed at improving transitions between specialised and primary care for HF.

What they did

HeartNetCare-HF is a disease management programme at the University Hospital in Würzburg (Universitätsklinikum Würzburg). 1-3 Patients who are treated for HF at the hospital can participate in the programme, where they are paired with a specialised HF nurse and receive personalised information about their condition. Information includes HF causes, symptoms, treatment, and dietary and physical activity advice.

After discharge from hospital the HF nurse continues to follow-up on the patient by phone and develops a treatment management plan with the patient to promote health and avoid a deterioration of their condition. In case of a worsening of the condition the HF nurse can react immediately and consult the treating GP or cardiologists. 1-3

What they achieved?

A clinical study showed that participation in the HeartNetCare-HF disease management programme improved mortality, guideline recommended medication and physical and mental wellbeing. 1-3

Links, references, and key reading



  1. Störk S, Faller H, Angermann C. HeartNetCare-HF© Würzburg. In: Würzburg U, ed., 2009.
  2. Universität Würzburg. HeartNetCare-HF am Universitätsklinikum Würzburg Strukturiertes Betreuungsprogramm für Patienten mit Herzschwäche, 2011.
  3. Deutsches Zentrum für Herzinsuffizienz Würzburg. Secondary 2015. http://www.chfc.ukw.de/aerzte/studien/inh-studie.html.