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Heart Failure
(Updated September 5th, 2018)
Heart Failure Definition:
Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. In some cases, the heart can't fill with enough blood. In other cases, the heart can't pump blood to the rest of the body with enough force. Some people have both problems. National Heart Lung and Blood Institute
Heart Failure Guidelines:
Michigan Quality Improvement Consortium: Heart Failure Guidelines
Care Management Interventions
Click Here to access the heart failure action plan
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Diagnosis Specific Concerns |
Care Management Intervention |
Patient Specific Interventions |
Care Manager Quick Tools |
Patient Quick Tools |
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Assessment |
Assess patients knowledge level on diagnosis |
Preparing for the visit |
What to Expect at the Physician Appointment
Handout - Preparing for the Appointment
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Diagnosis Education |
Provide education regarding HF diagnosis
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Discuss diagnosis with care manager
Review educational materials provided
Provide teach-back |
Michigan Quality Improvement Consortium: Heart Failure Guidelines Heart Failure Patient Teaching Guide.
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Medication Management |
Provide education on current medication therapy
Discuss side effects of medications
Discuss interactions |
Provide teach-back regarding medication understanding
Use a medication a medication log
Notify physician of side effects
Do not stop taking medication unless told to do so
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Guide to Heart Failure Medications
Free or Low Cost Medications - MDHHS
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Medication Fact Sheets:
Aldosterone Receptor Antagonists
Angiotensin II Receptor Blockers
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Weight Management |
Educate on patient on importance of monitoring daily weights
Educate patient on when to call physician regarding weight gain.
Provide weight monitoring log
Monitor patient weight
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Patient to monitor weight daily
Keep log of daily weights and bring to all appointments
Patient understanding to call provider if >2lbs in one day or 3-5lbs in one week
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Heart Failure: Checking Your Weight
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Fluid Management |
Monitor patient fluid intake
Provide patient education on fluid measurement and restriction
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Understand fluid restrictions provided by physician.
Review educational materials on fluid measurement
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Heart Failure: Watching Your Fluids
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Nutrition
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Educate on maintaining daily sodium restriction recommended by physician
Provide education on diet and tools for maintaining diet
Refer patient to a dietitian or nutritionist
Create diet plan
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Demonstrate ability to read food labels
Check labels for salt intake
Check food labels for fat content based on total calories
Decrease sodium in diet
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Living with Heart Failure from the American Heart Association
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Action Plan |
Educate patient on when to call primary care physician
Provide patient with HF action plan
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Demonstrate understanding of HF action plan and when to call physician’s office versus go to Emergency Room. |
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Smoking |
Provide education on smoking cessation
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Review materials provided on smoking cessation
Enroll in a smoking cessation program |
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How to Create a Plan to Quit Smoking
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Activity |
Provide education on exercise and CHF if recommended by physician
Create action plan Provide examples of different types of exercise
Educate patient on signs and symptoms of when to stop exercising
Refer patient to Cardiac Rehabilitation if necessary by physician. |
Check with provider prior to starting an exercise regimen
Understand warning signs and when to stop exercising Follow recommended treatment plan
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Guidelines for Exercising with Heart Failure MDHHS Cardiovascular Health, Nutrition, and Physical Activity |
Heart Failure: Activity and Exercise
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Managing stress |
Refer patient to a behavioral health specialist
Educate patient on healthy ways to manage stress |
Demonstrate understanding of healthy ways to manage stress |
Breathing Problems: How to Control Stress
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Common tests and labs |
Provide education on ordered tests |
Complete required testing and lab work
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Common Tests for Heart Failure
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For a printable version of the care management interventions Click Here
*This chart is not meant to be an inclusive list of interventions or resources for care management, but a starting point in working with patients with heart failure. Always check with your practice regarding the use of guidelines, resources and education.
Pathophysiology References
Toolkits
This section provides information on various toolkits to assist with the care management of heart failure patients.
Care Management Learning Resources
This section is for care managers who would like to get additional more specific information relating to heart failure.
