Objective:To establish the post-discharge disease management program for patients with chronic heart failure,and observe the effects of disease management on prognosis.Methods:Totally 207 patients with chronic heart failure,who were ad-mitted to hospital due to acute exacerbation,were enrolled.After discharge these patients were randomly divided into the study group (103 cases)and the control group (104 cases).Disease management program was implemented in the study group,and only routine outpatient follow-up was implemented in the control group.The clinical follow-up results one year after discharge were compared between the two groups.Results:Excluding the patients lost during follow-up,totally 1 88 patients completed the data collection,among which 98 cases were from the study group and 90 cases were from the control group.There was no significant difference regarding the baseline of clinical characteristics between the two groups (P >0.05 ).Follow-up results showed that compared with that in the control group,within the six months after discharged,the readmission rate,the multi-ple readmission rate,and the readmission or death joint events rate in the study group decreased significantly (P <0.05).The percentage of cardiac function NYHA class I to II and the left ventricular ejection fraction in the study group were higher than that in the control group (P <0.05),and the left ventricular end-diastolic diameter was in contrast (P <0.05).The score of Minnesota Living with Heart Failure Questionnaire in the study group was superior to that in the control group (P <0.05 ). Conclusions:The implementation of post-discharge disease management for the patients with chronic heart failure can signifi-cantly reduce the risk of the readmission,the multiple readmission,and the readmission or death joint events within the six months after discharge,and improve the patients’cardiac function and quality of life.