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Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors.<\/jats:p>","DOI":"10.1177\/1179546818809358","type":"journal-article","created":{"date-parts":[[2018,12,5]],"date-time":"2018-12-05T00:21:02Z","timestamp":1543969262000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":35,"title":["Moving From Heart Failure Guidelines to Clinical Practice: Gaps Contributing to Readmissions in Patients With Multiple Comorbidities and Older Age"],"prefix":"10.1177","volume":"12","author":[{"given":"Pupalan","family":"Iyngkaran","sequence":"first","affiliation":[{"name":"Northern Territory Medical Program, Flinders University, Darwin, NT, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Danny","family":"Liew","sequence":"additional","affiliation":[{"name":"School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 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