Care Coordination to Assess Improvement in Outcomes in Hospital Readmissions

Inclusion Criteria: Men and women over 18 years of age are included. Eligible subjects must be hospitalized with a primary diagnosis of ADHF or acute MI. The diagnosis of HF is established by the presence of typical symptoms, signs, and objective evidence of pulmonary congestion, elevated BNP or N-terminal pro B-type natriuretic peptide (NT-pro BNP) or impaired cardiac function. Acute MI is diagnosed by presence of chest pain, arm pain, or dyspnea with elevated Troponin and/or EKG changes suggestive of Acute coronary syndrome requiring intervention or optimal medical therapy. Exclusion Criteria: 1. Study informed consent will be obtained before enrollment in the study for Phase 1 and Phase 2 2. All subjects 18 years or above will be a criteria for inclusion for Phase 1 3. For Phase 2, men and women 50 years or older with positive Covid19 antigen test and one other risk factor as mentioned in the comorbid section of workflow will be enrolled in the intervention arm of the study; 4. For phase 2, subjects should be able to be randomized within 48 hours of Covid19 antigen positive status 5. Patients considered unreliable by the investigator concerning the requirements for follow-up visits