**Abstract**

In the era of a super-aged society, along with the rapid development of medical techniques to treat cardiovascular disease, there are an increasing number of aged patients with heart failure (HF). To cope with this near pandemic, coordinated-HF management combining hospital-based optimal therapy and home-based care is required. Accordingly, the concept of "living with HF" is advocated and is widely accepted as a key to improve patients' quality of life as well as prognosis. To achieve it, home visiting nursing services are essential. But these services have some difficulties. This chapter shows the importance of promoting self-management for patients with heart failure and intervention strategies in the home care setting.

**Keywords:** heart failure, self-management, re-hospitalization, home-based intervention, home visiting nursing
