Clinical Research Directory

Inclusion Criteria: Patients 1. Adult patients (≥18 years) with the main diagnosis of HF according to current guidelines (20), living at home; recruitment will be stratified by sex and limited to 60-70% for either sex. 2. Screen positive for one of the three clinical "sensitizing" questions, intended to identify potential palliative care (PC) needs: 'Would I be surprised if this patient were to die within one year?' * A "No" response indicates possible palliative care needs. 'Has this patient experienced 'escalating care events' at least twice in the past year, including i) unscheduled hospitalizations for HF, ii) emergency department visits for HF, iii) visits to out-of-hours primary care services for HF, and/or iv) other similar escalating care events?' * A "Yes" response indicates possible PC needs. 'Is this patient experiencing persistent or worsening multidimensional symptoms (e.g., physical, psychological, social, or spiritual concerns) despite optimal HF treatment, such that a palliative assessment is indicated (upon discretion of the treating physician or nurse)?' * A "Yes" response indicates possible PC needs. 3. patient's or informal caregiver's ability to use technology (e.g., having internet access, owning a smartphone or tablet, or having someone available who can assist them). 4. capacity to provide informed consent. Primary Caregiver: 1. Informal caregiver who is present with the patient during the implementation of the intervention 2. ≥18 years 3. capacity to provide consent. Healthcare professionals: Two professionals identified by the consortium in each site, willing to be trained in the intervention to perform the feasibility study. Exclusion Criteria: 1. Acute events leading to multiple outpatient visits not related to the HF diagnosis. 2. severe cognitive impairment or language disorders as determined by the attending healthcare professional based on clinical judgment and medical record review. 3. simultaneous participation in another study. 4. inability to read and write in the language in which the study is conducted. Primary caregivers: 1. Cognitive impairment or language disorders determined by the attending healthcare professional. 2. inability to read and write in the language in which the study is conducted. Health care professionals: a) Inability to read and write fluently in the language(s) required for the study site and for using the digital questionnaire.