Disease management programs have become an integral component of the overall care strategy of patients with heart failure. The standard approach with such programs is to enroll patients following discharge from hospital, and in general play little role in the in-patient phase of care. By ignoring the in-hospital phase an opportunity to significantly influence the quality of care is lost, likely contributing to persistently high readmission rates. At present, the major concerns with in-hospital care are the lack of consistent speciality involvement, incomplete investigation, lack of patient and family education, and failure to adequately prescribe proven medical therapies. This review underlines the need to complement the proven advantages of out-patient disease management programs by focusing more completely on in-hospital care. The likely advantages of a structured in-patient service and the practical difficulties in applying such a service are discussed.