title: A continuum of care model that works.
mesh_terms: D000359:Aftercare / Q000458:organization & administration; D003266:Continuity of Patient Care / Q000458:organization & administration*; D019468:Disease Management; D006333:Heart Failure / Q000191:economics* / Q000628:therapy*; D018575:Home Care Services, Hospital-Based / Q000458:organization & administration* / Q000706:statistics & numerical data; D006744:Hospital Bed Capacity, 100 to 299; D006764:Hospitals, Community / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D006801:Humans; D017146:Models, Organizational; D009741:Nursing Staff, Hospital; D010414:Pennsylvania