Chronic Conditions

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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

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America

Care Management Interventions

Click Here to access the heart failure action plan

Diagnosis Specific Concerns

Care Management Intervention

Patient Specific Interventions

Care Manager Quick Tools

Patient Quick Tools


Assess patients knowledge level on diagnosis

Preparing for the visit


Comprehensive Assessment tool

Heart Failure Readmission Assessment Tool

What to Expect at the Physician Appointment


Handout - Preparing for the Appointment



Diagnosis Education

Provide education regarding HF diagnosis

  • Causes
  • Risks
  • Symptoms
  • Treatment


Discuss diagnosis with care manager


Review educational materials provided


Provide teach-back

Patient Communication


Michigan Quality Improvement Consortium: Heart Failure Guidelines

Heart Failure Patient Teaching Guide.


Heart Failure Basics


What is Heart Failure



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


Guide to Heart Failure Medications


Medication Tracker

Free or Low Cost Medications - MDHHS



Medication Tracker


Medication Fact Sheets:


ACE Inhibitors


Aldosterone Receptor Antagonists


Angiotensin II Receptor Blockers





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


Patient to monitor weight daily

  • Tip- Monitor weight every morning before breakfast and medications, after urinating. Wear same type of clothes and weigh self on same scale


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


Heart Failure: Checking Your Weight

Heart Failure: Checking Your Weight


Heart Failure Checking Your Weight Handout

Heart Failure Monitoring Chart

Fluid Management

Monitor patient fluid intake


Provide patient education on fluid measurement and restriction



Understand fluid restrictions provided by physician.


Review educational materials on fluid measurement



Fluid Management Strategies in Heart Failure

Heart Failure: Watching Your Fluids


How to Limit Your Fluids




Educate on maintaining daily sodium restriction recommended by physician


Provide education on diet and tools for maintaining diet

  • Good vs bad food
  • Reading food labels


Refer patient to a dietitian or nutritionist


Create diet plan


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

  • Tips- Eat fresh or frozen vegetables not canned.
  • Leave salt shaker off the table
  • Do not cook with additional salt

Living with Heart Failure from the American Heart Association


Heart Failure Diet Guidelines

Heart Failure and Diet


Healthy Diet


Limiting Sodium


Action Plan


Educate patient on when to call primary care physician


Provide patient with HF action plan





Demonstrate understanding of HF action plan and when to call physician’s office versus go to Emergency Room.

HF Action Plan

HF Action Plan


My Heart Failure Workbook


Heart Failure Self-Check Plan


Provide education on smoking cessation


Review materials provided on smoking cessation


Enroll in a smoking cessation program

Smoking Cessation in Michigan


Smoking and Cardiovascular Disease

How to Create a Plan to Quit Smoking



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

  • Tips- Start slowly
  • Exercise at the same time each day so it becomes a regular part of the day

Guidelines for Exercising with Heart Failure

MDHHS Cardiovascular Health, Nutrition, and Physical Activity

Heart Failure: Activity and Exercise


Activity Tracker


Physical Activity, A Way of Life

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


How to Lower Your Stress

Four Ways to Deal with Stress: American Heart Association

Common tests and labs

Provide education on ordered tests

Complete required testing and lab work



Common Tests for Heart Failure


Diagnosing Heart Failure

Stress Test Fact Sheets


Electrocardiogram Fact Sheets

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


Heart Failure Pathophysiology

Provides basic pathophysiology for the care manager


CHF Pathophysiology - Mayo Clinic

The Mayo Clinic presentation of the pathophysiology of heart failure


This section provides information on various toolkits to assist with the care management of heart failure patients.


American College of Cardiology Toolkit

Provides information of heart failure practice solutions and prevention


Department of Veterans Affairs Heart Failure Toolkit

Developed through the Quality Enhancement research Initiave with the V.A., provides information for providers regarding heart failure to include clinical pathways, heart failure guidelines and education.


American Heart Association Heart Failure Toolkit

Toolkit provides information in the management of heart failure including, nutrition, fluid management, medication and much more.

Care Management Learning Resources

This section is for care managers who would like to get additional more specific information relating to heart failure.


2017 ACCF/AHA Guideline for the Management of Heart Failure

A Report of the Amercian College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Includes information on staging of heart failure, medication management, and treatments.


Health Literacy and Cardiovascular Disease

Discusses the importance of improving communication processes with patients can lead to improved cardiovascular outcomes from the Journal of Vascular Health Risk Management.


Evaluation of Patients for Ventricular Dysfunction and Heart Failure

Provides information regarding evaluation of ventricular dysfunction and heart failure and the three groups patients fall into. From the Journal of Cardiac Failure.


Fluid Management

Fluid management strategies from the Journal of Critical Care Nursing

Webinars and Presentations

MiCMRC Educational Webinar

Feb 28 2018

To receive a certificate of completion Click Here

Webinar replay video

Presented by

Emily Matson, MS

Theresa Han-Markey, MS, RD

Bionutrition Manager, U of M Nutrition Obesity Research Center


MiCMRC Educational Webinar

Feb 14 2018

To receive a certificate of completion Click Here

Webinar replay video

Presented by

Kristina Dawkins, MPH,  Clinical and Public Health Consultant

Michigan Department of Health and Human Services

Cardiovascular Health, Nutrition, and Physical Activity Section

Heart Disease and Stroke Prevention Unit

MiCMRC Educational Webinar

Apr 25 2018

To receive a certificate of completion Click Here

Webinar replay video

Presented by

Karen Jackson, RN Care Manager, MSN

Integrated Health Associates