[Organizational and managerial model for the patient with chronic heart failure]. / Modello organizzativo e gestionale del paziente con scompenso cardiaco cronico.

Patients with chronic heart failure show a range of care and global therapeutic management problems. The main elements for an efficient management are: hospital-territory integration based on a structured mode of operating and on the healthcare professional/patient relationship; rational continuity in the treatment; multi-disciplinarity of the interventions; the patient's active participation. In the light of these considerations the authors report their own direct experience describing the organizational and management model for patients with chronic heart failure during the various phases of treatment, from the global functional evaluation and treatment program to homecare management integrated with the general practitioner.