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Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. <i>J Am Geriatr Soc<\/i> 2003; 51: 549\u2013555, doi:10.1046\/j.1532-5415.2003.51185.x.","DOI":"10.1046\/j.1532-5415.2003.51185.x"},{"key":"6","doi-asserted-by":"publisher","unstructured":"6. Albert NM, Barnason S, Deswal A, Hernandez A, Kociol R, Lee E, et al. Transitions of care in heart failure: A scientific statement from the American Heart Association. <i>Circ Heart Fail<\/i> 2015; 8: 384\u2013409, doi:10.1161\/HHF.0000000000000006.","DOI":"10.1161\/HHF.0000000000000006"},{"key":"7","doi-asserted-by":"publisher","unstructured":"7. Van Spall HGC, Rahman T, Mytton O, Ramasundarahettige C, Ibrahim Q, Kabali C, et al. Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: A systematic review and network meta-analysis. <i>Eur J Heart Fail<\/i> 2017; 19: 1427\u20131443, doi:10.1002\/ejhf.765.","DOI":"10.1002\/ejhf.765"},{"key":"8","doi-asserted-by":"publisher","unstructured":"8. Takabayashi K, Fujita R, Iwatsu K, Ikeda T, Morikami Y, Ichinohe T, et al. Impact of home- and community-based services in the long-term care insurance system on outcomes of patients with acute heart failure: Insights from the Kitakawachi Clinical Background and Outcome of Heart Failure Registry. <i>Geriatr Gerontol Int<\/i> 2020; 20: 967\u2013973, doi:10.1111\/ggi.14013.","DOI":"10.1111\/ggi.14013"},{"key":"9","doi-asserted-by":"publisher","unstructured":"9. Kinugasa Y, Nakamura K, Hirai M, Manba M, Ishiga N, Sota T, et al. 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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, et al. 2022 AHA\/ACC\/HFSA guideline for the management of heart failure: A report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines. <i>Circulation<\/i> 2022; 145: e895\u2013e1032, doi:10.1161\/CIR.0000000000001063.","DOI":"10.1161\/CIR.0000000000001063"},{"key":"15","doi-asserted-by":"publisher","unstructured":"15. Jonkman NH, Westland H, Groenwold RH, Agren S, Atienza F, Blue L, et al. Do self-management interventions work in patients with heart failure?: An individual patient data meta-analysis. <i>Circulation<\/i> 2016; 133: 1189\u20131198, doi:10.1161\/CIRCULATIONAHA.115.018006.","DOI":"10.1161\/CIRCULATIONAHA.115.018006"},{"key":"16","doi-asserted-by":"publisher","unstructured":"16. Nakhjiri LZ, Darvishpour A, Pourghane P, Chaboki BG. 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Foody JM, Rathore SS, Wang Y, Herrin J, Masoudi FA, Havranek EP, et al. Physician specialty and mortality among elderly patients hospitalized with heart failure. <i>Am J Med<\/i> 2005; 118: 1120\u20131125, doi:10.1016\/j.amjmed.2005.01.075.","DOI":"10.1016\/j.amjmed.2005.01.075"},{"key":"25","doi-asserted-by":"publisher","unstructured":"25. Shah SJ. Why we should care about who cares for patients with heart failure with preserved ejection fraction. <i>Circ Heart Fail<\/i> 2022; 15: e009867, doi:10.1161\/CIRCHEARTFAILURE.122.009867.","DOI":"10.1161\/CIRCHEARTFAILURE.122.009867"},{"key":"26","doi-asserted-by":"publisher","unstructured":"26. Sun Y, Iwagami M, Komiyama J, Sugiyama T, Inokuchi R, Sakata N, et al. 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