Interactive voice recognition (IVR) technology uses speech recognition to deliver phone calls every 2 weeks to assess HF symptoms, offer additional educational material, offer medication information, receive self-care information from the system and track readmission and satisfaction at the end of the 3 month follow-up. The technology is easy to use with any type of phone system, has a broad reach into remote rural communities and requires minimal resources to implement. To date, the Heart Institute (HI) in partnerships with the Champlain LHIN community hospitals, has applied the use of a Heart Failure (HF) discharge tool for over 1000 patients from community hospitals in 2013-14 & the follow-up of 72 HF patients referred to the HI for daily Telehome Monitoring (THM). In 2015 the HI successfully implemented the expansion of the Acute Coronary syndrome IVR program to 4 community hospitals following 154 patients to date. Lessons learned from this expansion will be applied to the expansion of the Heart Failure IVR program to the community for improved self-care, communication with primary care physicians and collaboration between sectors as well as improved outcomes such as decreased readmission. This project aims to improve patient care and self-care, reduce readmission rates, and increase access to follow-up care in remote areas. This provides a multidisciplinary team for improved quality of life and better outcomes. The innovation can be easily exported to any health care organization across many sectors. It can be easily adapted to include transitional care follow-up at 48 hours after discharge as well as other chronic diseases such as diabetes. Last year the HI added a diabetes follow-up component to the ACS, cardiac surgery and HF patient populations with a diabetes nurse specialist addressing issues raised by the system, and preliminary results are promising.