心衰竭是一種病因複雜及多重共病的症候群，其治療目標在防範心衰竭反覆惡化衍生再住院。然而現行以急症為導向的片段性照護模式，對於病人的病因及共病照護需求，缺乏長期追蹤與整合管理，因而無法達成治療目標。為使病人照護無縫銜接，心衰竭個案管理師(heart failure case manager)以其進階的角色功能，提供全面性疾病管理：縱向由住院延伸至居家及門診，並銜接運動康復訓練計畫；橫向整合病人所需要的醫療及社會資源，並以互動的充能方式，激發個案參與自我健康促進。經由系統化的個案管理，以確保治療符合標準、病人主動參與、醫療資源永續。此種整合性照護對於病人以及醫療團隊的深遠影響，不僅止於精進外在疾病自我管理技巧，更喚醒内在追求優質照護的信念。

Heart failure (HF) is a syndrome with complex etiology and multiple comorbidities. The goal of treatment is to prevent HF aggravation induced re-hospitalization. However, current silo practice model focused on acute illness. The lack of longitudinal follow-up and fragmented management made the treatment goal unmet. An integrated care provided by HF case manager can extend the service longitudinally from hospitalization to ambulatory clinic and home care, and incorporates cardiac rehabilitation. HF case managers also horizontally integrate medical and social services and empower the patient in self-care and health promotion. Through the systemic case management, there were significant improvements in guideline adherence, patient active participation, and medical resource sustainability. In the long run, the disease manager-assisted integrated care will not only improve both patients and medical staffs in HF management skills, but also inspire their belief in pursuing high-quality care.