Our Cardiology Clinic nurse maintains a spreadsheet of high-risk heart failure patients whose chronic illness is managed by our providers. We use this list to monitor who has had frequent hospital admissions or ER visits, lost to follow-up, transitioned from homelessness, or any other life transitions that may require increased care coordination to maintain health. Our nurses engage with the patient by having frequent nurse visits which include clinical assessment, education, and provider-directed interventions. They also provide telephone follow-up and assessment phone calls, sometimes as frequently as daily, when a patient is in transition. The nurses prioritize bedside visits during an inpatient admission. Nurses engage the patient through timely (< 1 week) post-discharge follow-up and other varying and frequent modes of check-ins. Close collaboration between the nurses, providers, and multi-disciplinary teams to create patient-specific care is crucial when developing trust with our patients because they know that our team works closely together to meet their needs. Our nurses also collaborate with allied providers such as social work or pharmacy thus provide multiple opportunities for support and intervention. Weekly multidisciplinary meetings include discussions led by nurses regarding these patients and their specific clinical, educational, and communication needs. To further facilitate close management of our patients, our clinic has established lines of communication with community partners, such as case managers. Our nurses also provide occasional home visits, which galvanize trusting relationships when the patients see we are willing to go out of our way to help them.