The Cardio-share Telemedicine Cross-sector Collaboration Model for Managing Vulnerable Patients With Heart Failure

The goal of this observational study is to explore the potential of implementing a telemedicine-based cross-sector collaboration model to manage patients with frequent admissions with decompensated heart failure. The main question(s) it aims to answer are: * Characterization of conditions that make these patients vulnerable * Description of key-elements that makes possible to manage the patients with the cardio-share model Participants are: * Patients - will be helped to use the available telemedicine tools * General Practitioners - will be offered teleconferences with cardiologists (chat and video) on demand * Community health workers (caregivers at the patient home or in elderly home) - will be guided to assist the patients to use the available telemedicine tools Researchers will compare readmission rates (primary outcome) and quality of life of patients where the cardio-share management model is successfully implemented one year before and after the implementation.