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HF patients are hospitalized once a year&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Due to population growth&#44; aging and the increasing prevalence of comorbidities&#44; the absolute number of hospital admissions for HF is expected to increase by as much as 50&#37; in the next 25 years&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> HF is associated with an increasing cost burden&#58; the annual cost per HF patient in Europe ranges from 5000 to 15<span class="elsevierStyleHsp" style=""></span>000 euros&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Early detection of worsening HF symptoms and self-care for patients with HF is pivotal and a significant focus of multidisciplinary HF management programs worldwide&#44; yielding better quality of life&#44; lower readmission rates and reduced mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We used an evidence-based journey with care automation provided by UpHill Health S&#46;A&#46; to remotely monitor and optimize the follow-up of HF patients in an outpatient hospital clinic in Portugal&#46; In this manuscript&#44; we describe the preliminary results of this experience&#44; focusing on short-term outcomes and patient and healthcare workers&#8217; experience with the UpHill program&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Heart failure care journey optimization program</span><p id="par0025" class="elsevierStylePara elsevierViewall">The HF care journey optimization program was implemented in the Heart Center of Hospital da Cruz Vermelha Portuguesa &#40;HCVP&#41;&#44; a private hospital in Lisbon&#44; Portugal&#46; This unit specializes in the management of cardiovascular conditions&#44; with dedicated staff and facilities to support a program of cardiovascular health promotion&#44; prevention and early detection of cardiovascular disease&#44; treatment of acute and chronic cardiovascular conditions&#44; and appropriate follow-up and rehabilitation&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The key inclusion criterion was a previous diagnosis of HF with reduced or mildly reduced ejection fraction and at least one on-site cardiology appointment at HCVP in the previous 12 months&#46; The exclusion criteria were no cellphone or internet access and inability to provide a clinical history&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Patients were included after being given a detailed description of the care journey optimization program and providing informed consent&#46; UpHill is General Data Protection Regulation compliant and a certified class I medical device&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Care journey automation protocol</span><p id="par0040" class="elsevierStylePara elsevierViewall">The implemented care journey aimed to prevent emergency department visits and hospital admission for decompensation by focusing on remote monitoring of HF symptoms and detecting early signs of clinical deterioration&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The remote follow-up was performed by a communication assistant&#44; &#8216;Hilly&#8217;&#44; that helped track useful patient parameters&#44; such as weight or red flag HF symptoms &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The tracking included weekly monitoring for up to six months&#46; Alerts to the healthcare team were triggered according to predefined evidence-based criteria &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">When an alert was generated&#44; the healthcare team contacted the patient by phone to validate the clinical alert&#46; If validated&#44; three different actions could be adopted&#58; &#40;1&#41; remote adjustment of diuretic dosing &#40;if the patient was in New York Heart Association &#91;NYHA&#93; functional class I or II&#41;&#59; &#40;2&#41; scheduling an in-person appointment for the following days &#40;if in NYHA III&#41;&#59; &#40;3&#41; referral to the emergency department &#40;if in NYHA IV&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> provides a visual overview of the automated remote monitoring program&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">During the last two weeks of the protocol&#44; each participant was asked to respond to a satisfaction survey to assess how this care journey program was perceived by HF patients&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">Between May and October 2022&#44; 51 patients &#40;mean age 74 years&#59; 70&#37; male&#41; were included in the care journey automation protocol&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">On average&#44; each patient received 15 automated communications&#46; Most patients &#40;70&#37;&#41; responded to the weekly communication and used the web form rather than the voice phone channel to answer the questionnaire&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The weekly automatic communications generated 69 alerts&#46; After phone contact by the nursing team aiming to assess the specific triggers of the alert and validate or reject it&#44; the overall sensitivity and specificity of the remote monitoring weekly communication were 66&#37; and 62&#37;&#44; respectively&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Of the 22 patients who answered the satisfaction survey&#44; 95&#37; characterized the care program as safe and felt closer to the healthcare team&#46; All patients would recommend it to a friend or relative&#46; In addition&#44; unstructured interviews with healthcare professionals participating in the program demonstrated a general feeling of satisfaction and added value to the standard of care&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Overall&#44; implementing this care journey automation program targeting HF patients positively impacted patients&#44; healthcare professionals and the institution&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">From the patients&#8217; standpoint&#44; this care journey optimization program fostered confidence and security through regular remote monitoring by the healthcare team&#46; In addition&#44; it provided the patient with awareness and empowerment for managing HF through tracking weight and relevant symptoms&#46; Patients with HF and more effective self-care have a better quality of life and lower mortality and readmission rates than those with lower levels of self-care&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Overall&#44; this optimization program aimed at prevention and early detection of HF decompensation&#46; As previously demonstrated&#44; telemedicine strategies appear to be associated with reduced short-term cardiovascular-related hospitalization and mortality risk in patients with HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Discussing the impact on healthcare professionals and the organization of clinical teams is also interesting&#46; The automation of repetitive monitoring tasks for patients with chronic HF was seen positively&#44; with continuous monitoring of stable patients &#40;while generating alerts for weight increase or congestive symptoms&#41;&#46; Healthcare professionals involved in the program&#44; including a strong contingent of the nursing team directly involved in patient contact&#44; perceived greater efficiency of daily routines through automatic prioritization of patients who should be contacted first&#46; Interestingly&#44; when we compared the estimated amount of time that would be spent by healthcare staff for weekly follow-up by phone of every HF patient with performing only the alert-triggered follow-ups using the care journey automation program&#44; we estimated that the inclusion of this evidence-based journey with care automation could safely save 60 hours of clinical workload&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Finally&#44; healthcare institutions might benefit from care journey optimization programs like the one described herein&#46; This type of program can provide a thorough mapping of the care journey of HF patients&#44; improving the allocation of resources to actual needs and&#44; in this way&#44; delivering value-based healthcare by improving health outcomes and minimizing costs&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">To sum up&#44; this pilot project with an automated monitoring protocol targeting the care journey of outpatient HF patients was able to streamline medical contact and optimize human resources &#40;potentially reducing costs for institutions and society&#41; while delivering a safe digital health solution that elicited a strong positive feeling in patients and healthcare staff&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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                  \t\t\t\t">1&#46; Body weight in kg2&#46; Are your legs or ankles more swollen than usual&#63; &#40;Yes&#47;No&#41;3&#46; Are your clothes or shoes tighter than usual&#63; &#40;Yes&#47;No&#41;4&#46; Have you used more pillows when sleeping in the last week&#63; &#40;Yes&#47;No&#41;5&#46; Have you experienced increased shortness of breath during your daily activities&#63; &#40;Yes&#47;No&#41;Questions 2 and 3 &#8211; edema groupQuestion 4 and 5 &#8211; dyspnea group&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46; Increase in body weight of over 3 kg2&#46; Increase in body weight of over 2 kg and answer Yes to one of questions 2&#8211;53&#46; Answer Yes to at least one question from the same group in two consecutive communications4&#46; Answer Yes to one question in each group in the same communication&nbsp;\t\t\t\t\t\t\n
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