To answer the questions in the assessment elements we mainly used the basic literature search provided for the whole project. Additionally, two more systematic searches were used: one performed by ORG and ECO domains (described in methodology of ECO domain) and one perfomed by EFF, SAF and ECO domains (described in SAF domain).. The results are provided in descriptive way.

RM through STS is a strategy that builds on a patient’s self-monitoring. To be effective, self-monitoring requires the local HF service to be easily accessible to the patient and their family/carer. TM can be useful in this situation and patients may develop expertise through the timely feedback provided by monitored data and from the health professional contact {100}.

A published communication strategy is important, including patient support strategy, communication between patient: nurse, patient: medical doctor, patient: pharmacist, the brochures, diaries to record daily control measurements, web pages with disease information and with instructions, instructions for family members  to share a best practise.

In the heart of communication and cooperation strategy in the studies there was always a nurse. A consistent nurse case manager who cares for the patient and connects family, tries to understand goals and specific outcomes, provides information and monitors patient and communicates and cooperates with other members of health team to help them understand the patient. She/he also coordinates services for the patient {240}.

In the matched cohort study of a disease-management heart failure program employing a structured telephonic nursing intervention {11}, communication between nurses (who made the telephone calls to patients) and phycisians and, between nurses and the health plans’ case managers occurred usually after each scheduled patient call. In the communication between nurses an phycisians, communication took place via letters, facsimiles and telephone calls. The content of the communication included recommendations for further counseling topics or clarification of patient-reported information. Two-way communication was encouraged. In the comunication between nurses and the health plans’ case managers, the communication aimed at resolving or enquiring on information on issues relating to the plan benefits such as durable medical equipment procurement, mental health visit coordination, transportation difficulties, or financial barriers to adhering to physician recommendations. 

Findings from TRICARE's disease management programs for asthma, congestive heart failure, and diabetes patients suggest a program cordinated by a care manager {3}:

• an initial 40- to 50-minute baseline assessment by telephone with a care manager;
• monthly follow-up telephone calls to set goals, assess progress toward those goals, and educate patients about their conditions and self-management;
• educational materials specific to the patient’s needs (eg, pamphlets, videos, cookbooks); and
• newsletters and Internet-based materials.