have hf as one of their discharge diagnoses;

have new york heart association (nyha) class ii to iv symptoms or have nyha class i symptoms

have had at least one other hf-related hospitalization or emergency department visit in the previous year;

are discharged to home;

pass a mini-cog screen

understand english;

have access to a phone.

have scheduled procedures and/or surgeries during hospitalization;

have depressive symptoms (receive a score of 3 or above on the patient health questionnaire-2 (phq-2) have documented medical diagnosis or diagnostic evidence of liver cirrhosis;

have renal failure (serum creatinine greater than 2.0mg/dl)