Congestive heart failure (CHF) is a significant health problem in Canadian adults and continues to be a leading cause of morbidity and mortality. It has been cited as the most rapidly growing category of cardiovascular disorder. There is little likelihood that patients experiencing CHF will leave the health care system until death. Typically, they move between health care sectors, being repeatedly admitted and discharged from each. In our system today, where institutional and community sectors are separately organized, separately funded and poorly linked at the point of service delivery, these patients are at high risk for discontinuity of care.