Transitional Health Systems is a home-based disease management and tele-monitoring service. After a patient is discharged, THS will allow you to closely monitor them. We provide the patient with all the disease education, lifestyle management tools, and symptom management tools they will need to stay out of the hospital and properly manage their diagnosis on a day to day basis so they can regain their independence. The program consist of in home education using a method called "the teach back method" as well as online self learn education. The patient and their family gain access to a complete online education portal equipped with over 22 educational modules. We provide "state of the art" medical grade durable medical equipment for the patient for accurate daily vital sign monitoring which reports daily to us through our proprietary CardioTrack ™ program. All of our equipment is bluetooth driven so the patient can effortlessly take their vital signs every day. All they have to do is step on the scale and then their weight will bluetooth from their scale to our software immediately. Every day in our software we can view a trend dashboard that will allow us to quickly identify trends in vital signs and early warning signals so we can identify exacerbation. We have built in readmission risk assessment tools that we can quickly triage a patient with upon entrance into the program as well as daily. It also allows us to identify barriers outside of the congestive heart failure realm such as mental health that will pose a threat to the success of the patient getting healthy. We aim to reduce readmission rates while also increasing patient satisfaction. Our mission is to help improve quality of life in congestive heart failure patients by helping them maintain their independence while becoming healthy and strong.