1. Supporting Patients with CHF Care Transformation Collaborative of R.I. MAUREEN CLAFLIN, MSN, RN. NCM UNIVERSITY MEDICINE GOVERNOR STREET PRIMARY CARE CENTER 1

2. Heart Failure: Caring for Patients in the Community 2

3. 3 Stages of Heart Failure Acute  Left-sided heart failure: This is the most common type of heart failure: ◦systolic heart failure: prevents the left ventricle from proper pumping ◦diastolic heart failure: dysfunctional filling of right ventricle

4. Stages of Heart failure Acute  Right-sided heart failure: This usually happens simultaneously with left-sided heart failure. When the left ventricle fails it results in increased pressure, and subsequent damage, to the right side of the heart. The right side of the heart cannot pump efficiently, causing fluid to accumulate in the veins, which may cause lower extremity edema. 4

5. Stages of Heart failure Chronic  Congestive heart failure: ◦Left sided CHF indicates damage to left ventricle causing pulmonary edema. ◦Right sided CHF indicates damage to right ventricle and ability to effectively pump blood to lungs causing fluid accumulation in lower extremities and abdomen. 5

6. 6 Evidence Based Guidelines for Treatment Acute/chronic HF treatment:  Medication management – diuretics, beta-blockers, ACE inhibitors, ARBs  O2 therapy  Surgical repair if indicated  Cardiac rehabilitation  Lifestyle changes: o Weight management o Smoking cessation o Exercise as tolerated o Stress management

7. 7 Care Management: NCM Interventions Education Teaching patient self-management Coaching sessions Weekly/monthly check-in/management Support Community resources

8. Patient Self-Management Teach patients to know “their problem list” Weight monitoring Medication management Know “red flags” and when to call physician Know how to access physicians 24/7 Exercise Stress management 8

9. 9 Your Goal Weight: Green Zone: All Clear  No shortness of breath  No swelling  No weight gain  No chest pain  No decrease in your ability to maintain your activity level Green Zone Means :  Your symptoms are under control  Continue taking your medications as ordered  Continue daily weights  Follow low salt diet  Keep all physician appointments Yellow Zone: Caution If you have any of the following signs and symptoms:  Weight gain of 3 or more pounds in 2 days  Increased cough  Increased swelling  Increase in shortness of breath with activity  Increase in the number of pillows needed  Anything else unusual that bothers you  Call your physician if you are going into the YELLOW zone Yellow Zone Means :  Your symptoms may indicate that you need an adjustment of your medications  Call your physician, nurse coordinator, or home health nurse. Name:___________________________ Number:__________________________ Instructions: _______________________ __________________________________ Red Zone: Medical Alert  Unrelieved shortness of breath: shortness of breath at rest  Unrelieved chest pain  Wheezing or chest tightness at rest  Need to sit in chair to sleep  Weight gain or loss of more than 5 pounds in 2 days  Confusion Call your physician immediately if you are going into the RED zone Red Zone Means : This indicates that you need to be evaluated by a physician right away  Call your physician right away Physician___________________________ Number____________________________

10. 10 External Care Team/Resources Lifespan Transition of Care program VNA/home care cardiac care programs o Infusion resources/supports o Advanced illness management program Tele Health Behavioral Health Nutrition Hospice

11. Case Presentation Toni 88 yo patient with long-standing right-sided HF with CHF Hospitalizations every 3-4 weeks for CHF for IV diuretics Managed at home with support of VNA cardiac team and eventually hospice services. Receives IV Bumex 4-5 days/week/support Has not been hospitalized in 8 months Provider/care team home visits 11

12. 12 Heart Failure: Total Cost of Care Complex disease to manage Frequent ED encounters/hospitalizations costly Moving care/management to the community setting less costly and can accomplish:  empowers patient/caregivers to manage disease  consistent care by primary physician and care team  early identification of concerns  support for the stages of care