AN INTERDISCIPLINARY GUIDE FOR SAFER CARE ......5 of 46 2017 o Interdisciplinary Guide for Safer...

AN INTERDISCIPLINARY GUIDE FOR SAFER CARE TRANSITIONS AND FEWER READMISSIONS FOR HEART FAILURE

Contributing Author: Cherilyn L Heggen, PhDSenior Clinical & Team Lead Educational Strategy & Content PRIME Education, LLCTamarac, FL

Reviewer: Kathleen A Jarvis, MS, RN, CCMClinical EducatorOptum HealthFort Lauderdale, FL

Accredited for 2.0 hours of ACCME, ACPE, ANCC, and CCMC credit. For learning objectives, faculty, and accreditation information, please refer to page 46. Please review this information before you start this activity. This CME activity expires on October 31, 2018.

There is no fee for this activity as it is sponsored by PRIME® through an educational grant from Novartis Pharmaceuticals.

Cheri Lattimer, RN, BSNExecutive DirectorNational Transitions of Care CoalitionWashington, DC

James E Lett, MD, CMDFamily Medicine Physician Medical DirectorAvar ConsultingRockville, MDDirector of the National BoardNational Transitions of Care CoalitionWashington, DC

Interprofessional Steering Committee:

Akshay S Desai, MD, MPHAssistant Professor of MedicineHarvard Medical SchoolDirector, Heart Failure Disease Management ProgramBrigham and Women’s HospitalBoston, MA

H Edward Davidson, PharmD, MPHAssistant Professor of Clinical Internal MedicineEastern Virginia Medical SchoolPartner Insight Therapeutics, LLCNorfolk, VA

Anwar K Malik, MDCardiologistFrederick Memorial HospitalCardiovascular Specialists of FrederickFrederick, MD

Kelley M Anderson, PhD, FNP, CHFN-KAssociate Professor of NursingGeorgetown University School of Nursing & Health StudiesNurse Practitioner, Division of CardiologyMedStar Georgetown University HospitalWashington, DC

2 of 46 © 2017 PRIME Education, LLC. All Rights Reserved. www.primeinc.org

Table of Contents Introduction

Purpose and Scope ............................................................................................................................................ 3

Guiding Principles .............................................................................................................................................. 3

Scope of the Problem in Heart Failure ............................................................................................................. 3

Ensuring Timely and Accurate Diagnosis of Heart Failure ............................................................................. 4

Guideline-Directed Treatment and Management of Patients with Heart Failure ......................................... 5

Barriers to Effective Care Transitions in Heart Failure ..................................................................................... 7

Benefits of Continuity of Care ......................................................................................................................... 10

Outcomes Expected from Implementation of These Recommendations................................................... 11

Considerations in Heart Failure Transitions of Care

Tools to Facilitate Transitions of Care in Heart Failure .................................................................................. 11

Care Setting Commitment .............................................................................................................................. 12

Patient and Family/Caregiver Engagement and Education in Transitions of Care .................................... 12

Working with the Interprofessional Team in Transitions of Care .................................................................. 14

Transition Planning ........................................................................................................................................... 20

Medical Records and Information Transfer .................................................................................................... 23

Medical Reconciliaton and Drug Interaction Prevention .............................................................................. 23

Support and Follow-Up Care .......................................................................................................................... 25

Advance Care Planning .................................................................................................................................... 25

Implementation of a Care Transition Program

A Care Transition Pathway for Heart Failure .................................................................................................. 27

Quality Measures and Assessment of Care Transition Management .......................................................... 27

Summary

Summary ........................................................................................................................................................... 29

References ........................................................................................................................................................ 30

Resources

Appendix I. Additional Resources .................................................................................................................. 33

Appendix II. Taking Care of My Heart Failure Health Care ........................................................................... 34

Appendix III. Letter to Healthcare Providers .................................................................................................. 36

Appendix IV. Essential Heart Failure Care Transition Interventions ............................................................. 37


INTRODUCTION

Purpose and Scope

This white paper focuses on transitions of care experienced by patients with HF (HF) as they navigate through different care settings, including primary care, specialty care, acute care settings, long-term care and skilled nursing facilities, other post-acute care sites, and the patient’s home. Designed for healthcare professionals across the care continuum, the purpose of this guide is to outline pathways to:

• Break down gaps and barriers associated with poor care transitions

• Support safe and quality patient-centered transitions of care

• Improve education and awareness

• Enhance efficient, timely, and accurate bi-directional transfer of essential patient health information

• Equip patients and families/caregivers for self-management and advocacy

Guiding Principles

The guiding principle of this transitions of care pathway for HF is that necessary care transitions should be safe and unnecessary transitions (eg, hospital readmissions) should be prevented. In 2011, the National Transitions of Care Coalition released “Seven Essential Intervention Categories” that provide the underlying principles for the transition strategies for HF patients discussed in this guide. These include:

1. Medication management

2. Transition planning

3. Patient and family engagement/education

4. Information transfer

5. Follow-up care

6. Healthcare provider engagement

7. Shared accountability across providers and organizations

The “Seven Essential Intervention Categories” align with the key principles central to transitions of care highlighted in the joint “Transitions of Care Consensus Policy Statement” released in 2009 by multiple national healthcare organizations, including the American College of Physicians (ACP), Society of General Internal Medicine (SGIM), Society of Hospital Medicine (SHM), American Geriatrics Society (AGS), American College of Emergency Physicians (ACEP), and Society of Academic Emergency Medicine (SAEM).1

To specifically address transitions of care for patients with HF, substantial work has been done investigating the underlying causes and assessing the impact of interventions to reduce the incidence of hospital readmissions, the key findings of which are summarized and applied to the recommendations outlined in this guide for the interdisciplinary HF team.

Scope of the Problem in Heart Failure

HF is, most often, a chronic, incurable progressive disease. Patients with HF experience multiple transitions and providers throughout the course of their disease, including transitions from home to emergency room, emergency room to hospital, hospital then back to home or to post-acute care, and post-acute care to home. HF refers to the inability of the heart to maintain adequate circulation of blood to meet the body’s metabolic needs caused by impaired cardiac pump function. Currently, an estimated 6.5 million adults are diagnosed with HF in the US, with an incidence of 960,000 new cases each year.2,3 The number of American adults living with HF is expected to rise to

An Interdisciplinary Guide for Safer Care Transitions and Fewer Readmissions for Heart Failure


8 million by 2030.2 The Centers for Medicare and Medical Services (CMS) identified HF as one of three diagnoses with high financial costs and in 2012 established the Hospital Readmissions Reduction Program (HRRP) to include HF, along with myocardial infarction and pneumonia.4

Despite recent significant advances in management, HF continues to pose a significant economic burden on the US healthcare system, with annual healthcare costs of more than $30 billion in 2012.3 The total cost of HF is projected to increase to almost $70 billion by 2030. Aside from the financial burden, HF also presents a significant burden to patients in terms of high mortality rates and repeated hospitalizations. HF is the documented cause of 1 in 8 deaths in the U.S. The 5-year HF mortality rate remains high at ~50%. 2,3

Studies have shown that ~24% of patients hospitalized for HF are readmitted within 1 month of discharge and ≥50% return to the hospital within 6 months of discharge.5,6 While recurrent HF and related cardiovascular conditions account for about 50% of readmissions, other comorbidities often lead to re-hospitalizations for HF patients, especially as more people are living longer with HF and experiencing additional comorbidities associated with aging and their disease. Comorbidities, including hypertension, arrhythmias, coronary artery disease, pneumonia, renal failure, and chronic obstructive pulmonary disease (COPD), along with factors of non-adherence to diet and medications, contribute to the higher rates of re-hospitalization and care transitions experienced by patients with HF. 7,8

Addressing these underlying issues prior to discharge, in addition to adequate fluid reduction and optimizing medical therapy, is key in reducing the risk for re-hospitalization.7,9 In their 2015 Scientific Statement, the American Heart Association (AHA) identified several specific strategies to address these factors during transitions for patients with HF, including medication management, timely follow-up appointments, healthcare provider communication, and signs/symptom management.10 Improving continuity of care throughout care transitions is essential to optimizing health, quality of life (QoL), and outcomes for patients with HF.

Ensuring Timely and Accurate Diagnosis of Heart Failure

HF is a complex clinical syndrome caused by either structural or functional abnormalities of the heart, resulting in an impaired ability to support physiological circulation.11 Common symptoms of HF include shortness of breath (exertional, orthopnea, and paroxysmal nocturnal dyspnea), fatigue, and swelling in the ankles.12 Symptoms may be a result of pulmonary and systemic congestion, structural abnormalities causing or resulting from HF, or complications of therapy.13 The disease is manifested as impaired ventricular contraction, impaired ventricular relaxation, or both.14 Several conditions are associated with HF, the most important of which is hypertension. Elevated levels of systolic blood pressure pose a higher risk for the development of HF.15,16 Treatment of both systolic and diastolic hypertension reduces HF risk by half,17-19 hence strategies for management of hypertension are a critical component of HF prevention efforts. Other modifiable risk factors include diabetes mellitus, metabolic syndrome, and atherosclerotic disease.20 Structural abnormalities leading to HF include cardiomyopathy that is differentiated into dilated, familial, metabolic, toxic, tachycardia-induced, inflammation, peri-partum, and others.20 Defining the etiology of HF with appropriate cardiomyopathy type is essential to guide treatment strategies.11

Initial evaluation of an HF patient involves a thorough history and physical examination, as well as lab tests (Figure 1). Clinical scoring systems such as Framingham criteria or National Health and Nutrition Survey (NHANES) criteria are used to determine HF diagnosis.21,22 Guideline recommendations for serum biomarkers include measurement of B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) to support clinical decision-making regarding the diagnosis of HF and for establishing prognosis or disease severity in chronic HF. Measurement of BNP or NT-proBNP and/or cardiac troponin is useful for establishing prognosis or disease severity in acutely decompensated HF. Moreover, these biomarkers can also be used to guide therapy in select patients. Other biomarkers of myocardial injury or fibrosis may be useful for risk stratification in patients with acutely decompensated HF.11,20 Initial evaluation of HF patients also includes 12-lead electrocardiogram, echocardiogram, and chest X-ray to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may contribute to the symptoms.




Left ventricular ejection fraction (LVEF) is an important measurement in HF to guide treatment decisions. Two-dimensional echocardiogram coupled Doppler flow studies is performed to assess LVEF, left ventricular size, wall thickness, wall motion, and valve function. Radionuclide ventriculography can be performed to assess LVEF and volumes. Patients with impaired ventricular contraction have HF with reduced ejection fraction (HFrEF) and those with impaired ventricular relaxation have HF with preserved ejection fraction (HFpEF). HFrEF is defined as a left ventricular ejection fraction (LVEF) ≤40%, while HFpEF is defined as an LVEF ≥50%. Patients with LVEF in the range of >40% to 50% are in the intermediate group.20

Management strategies are categorized based on whether the patients have HFrEF or HFpEF. Invasive evaluation includes hemodynamic monitoring with a pulmonary artery catheter to guide therapy in some patients who have respiratory distress or clinical evidence of impaired perfusion.20 Following diagnosis, multivariable risk scores such as the Seattle HF Model, HF Survival Score, CHARM Risk Score, and CORONA Risk Score for all patients, I-PRESERVE Score for HFpEF, and EFFECT risk score, ESCAPE risk model, and ADHERE classification, AHA Get With The Guidelines Score, and OPTIMIZE HF Risk Prediction Nomogram are used to predict outcome in patients with HF.20 In practice, local cardiologists may initiate care and then refer to HF specialists if the case is severe, complex, or if there are recurrent episodes of instability. Clinicians should know how to evaluate patients for their eligibility for advanced therapies and know when to engage the subspecialist in care.

Guideline-Directed Treatment and Management of Patients with Heart Failure:

The American College of Cardiology (ACC) and AHA have jointly developed a staging system ranging from A through D for HF patients based on clinical assessment (Table 1).20 The New York Heart Association (NYHA) further classifies stages C and D HF patients based on functional capacity and symptoms of the disease (Table 1).20

The primary goals of HF treatments include improvements in symptoms, survival, and quality of life. Additional goals include prevention of disease progression and recovery of LVEF. The majority of guideline-directed therapies are for HFrEF patients.20,23,24 Initiation of treatment is based on ACC/AHA staging and NHYA functional classification. Treatment strategies for ACC/AHA Stage A HF patients include management of modifiable risk factors and comorbidities as well as risk reduction. For stage B patients, treatment goals include prevention of disease progression and improvement in survival. Angiotensin converting enzyme inhibitors (ACEi)25 or angiotensin-receptor blockers (ARB)26,27 are recommended to reduce morbidity and mortality in individuals with HFrEF. Additionally, select beta-blockers (bisoprolol, carvedilol, or metoprolol, also known as evidence-based beta blockers) have been shown to reduce mortality, in these patients, especially those with a history of coronary artery disease.28-30 Also, coronary artery disease patients with HFrEF benefit from the addition of statin therapies.31,32 In eligible patients, implantable cardioverter defibrillator (ICD) placement to prevent sudden cardiac death or cardiac resynchronization therapy (CRT) to improve cardiac performance and symptoms to reduce morbidity and mortality may be beneficial.20 A wide array of guideline-directed treatment options is available for stage C HFrEF patients. These include ACEi or ARB and beta-blockers as in stage B patients.24 The 2016 and 2017 ACC/AHA/HFSA focused updates of the 2013 guideline for management of HF includes newly approved, novel therapies – sacubitril and ivabradine.

Figure 1. HF Diagnostic Criteria3



The combination product of valsartan (ARB) and the nephrolysin inhibitor, sacubitril referred to as angiotensin receptor neprilysin-inbihitor (ARNI) targets both the natriuretic peptide (NP) as well as the renin–angiotensin–aldosterone system (RAAS).24,33 Efficacy was based on the results of the PARADIGM HF trial that showed that compared to the ACEi, enalapril, ARNI significantly reduced cardiovascular mortality, all-cause mortality, risk of HF-related hospitalization, HF-related symptoms and physical limitations.34 In addition to the above mentioned therapies, appropriate stage C patients may also experience morbidity and mortality benefit from further neurohormonal blockade using a mineralocorticoid receptor antagonist (MRA), specifically aldosterone receptor antagonists such as spironolactone and eplerenone. 35-37

The second new therapy included in the ACC/AHA/HFSA update is ivabradine, an If channel inhibitor, which reduces heart rate without negative inotropic effects, to reduce HF-related hospitalization for stage C patients with NYHA Class II-III HFrEF patients, with resting heart rate of ≥ 70 bpm, who are receiving guideline directed therapies including a beta-blocker.24 This recommendation is based on the data from the SHIFT trial showing that heart rate reduction with ivabradine along with guideline-and evidence-based treatment significantly reduced major risks associated with HF such as cardiovascular death or hospital admission.38 For stage C patients, it is important to alleviate symptoms such as fluid retention. Diuretics and, in some cases, dopamine or vasopressin antagonists are used to increase water secretion and alleviate congestion.23 Some patients may benefit from the addition of digoxin for persistent symptoms.39 Addition of a fixed dose of combination of isosorbide dinitrate and hydralazine to standard therapy has been shown to increase survival among black patients with NYHA class III-IV disease.40

There are limited guideline-recommended therapies for HFpEF patients. At this time, no classes of medications have shown an improvement in survival.11 Pharmacological treatment for this group of patients include managing comorbidities

Table 1. Staging and Classification of HF20

ACC = American College of Cardiology Foundation; AHA = American Heart Association; HF = heart failure



such as hypertension using beta-blockers, ACEi and ARB, as well as diuretics for symptom relief due to volume overload. Coronary revascularization in some coronary artery disease (CAD) patients and management of atrial fibrillation are also important considerations.24 For select HFpEF patients, aldosterone receptor antagonists such as spironolactone may help decrease HF-related hospitalizations. ARB may be considered to decrease hospitalizations for stage C HFpEF patients. Recent data have shown that nitrates or phosphodiesterase-5 inhibitors to increase activity or QoL is ineffective and hence not recommended in these patients. 24,41,42

In patients with stage D refractory disease, advanced HF therapies to maintain systemic perfusion and end-organ performance need to be considered in addition to the management strategies for stage C patients. Advanced HF therapies may include inotropic support, coronary revascularization, mechanical circulatory support (MCS) including left ventricular assist device (LVAD) and biventricular assist device (BIVAD), or heart transplant. During this stage, patients require counseling for palliative and end-of-life care options.23,43 The recommendations for the treatment of HF are summarized in Figure 2.

Barriers to Effective Care Transitions in Heart Failure

Delivery-System-Level Barriers

• Tension between reducing length of stay vs. optimization of HF management. Sometimes optimal HF management may lengthen the hospital stay, which may be contradictory to utilization management concerns. In other cases, hospital stay may be lengthened due to payment policies and reimbursements when the patients would most benefit from post-acute care. These non-clinical tensions are not always in the best interest of the patient.

• Insufficient or ineffective information transfer and “dueling health information systems.” When HF patients are moved from one setting to another, gaps in care can occur when insufficient information is communicated. These communication gaps may include imaging reports missing the actual images, incomplete contact information for the referring provider, and lack of follow up on test results pending at the time of transfer. Communication between providers often occurs through electronic health records, which may not communicate efficiently or be available at all depending on provider’s systems and access. Better electronic integration is needed to transmit information efficiently between providers and health care settings in a meaningful way. In addition, information is often not communicated to patients and caregivers effectively. Transitioning patients and families may actually be given too much information, not too little, at departure from the hospital. Discharge instructions may be long and involved, and often come from multiple providers (nurse practitioners, physician assistants, physicians, case manager, HF program director, etc.), leaving patients and caregivers confused as to which are the key instructions.

Figure 2. Treatment of Heart Failure20,23,24

GDMT = guideline-directed medical therapy; MRA = mineralcorticoid receptor antagonist.



• Inadequate medication management and education. Medication management can also be a challenge for patients with HF. Medications may not always be reconciled at each care transition. Further, healthcare providers and caregivers and treatment facilities are not always informed about the medications and changes in treatment, leading to medication errors, adverse events, and rehospitalizations.44 HF medication regimens are often complex, leading to confusion, particularly with medication changes related to formularies resulting in omissions or therapeutic duplications.45

• Lack of continuity of care. Continuity in treatment and support of patient preferences are often missed or overlooked with lack of appropriate communication. Information shared with the patient at the point of leaving the hospital can be confusing and not clearly stating the next steps for the patient and family caregiver. In many cases, a care plan, medication regime, or transition summary is not communicated to the next level of care, which may include multiple providers, i.e., specialists, home health, durable medical equipment durable medical equipment (DME) providers, and the patient and family/caregiver.

• Access to outpatient care. Timely access to outpatient care continues to be a significant barrier for HF patients. Patients may experience inadequate transportation, language barriers, and challenges with costs and medication adherence. In addition, patients may not know with whom they need to schedule appointments, especially in the outpatient setting. Patients not currently established with a primary care physician (PCP) or specialist may experience further delays in getting an appointment as a new patient.

• Lack of follow-through with HF program. Nearly all hospitals have a “HF Program” to reduce hospital readmissions. However, those successful programs may end when patients are discharged from the hospital and often do not continue to the next site of care. Patients and caregivers may be left not knowing what to do regarding medications and services provided through that program and other providers may not even be aware that the patient is in a HF program.

• Discharge information delay. Discharge/transition summaries to the next site of care may be delayed or never arrive at all. In some cases, hospital clinical teams that discharge a patient may be off-duty by the time the patient arrives at the next site of care and they are unable to provide information or clarification to the new care team. Information is often delayed to the patient’s PCP after a hospital stay and in some cases the PCP may not know the patient was hospitalized until a later office visit. In the case of a transfer to home with home health, an appropriate handover from one level of care to another does not always occur to facilitate a positive transition.

• Lack of follow up. At the system level, processes may not be in place to ensure sufficient follow up with patients after a transition to a new care setting. Although calls to patients post-discharge are a good strategy, they do not always occur, or patients may not respond.

• Key providers are not aware of hospitalizations. HF patients often have comorbidities and may be hospitalized for reasons other than their HF. Regardless of the reason for admittance, the local physician or other key providers may not know that the patient was in the hospital and are unable to continue a new care regimen.

• Insufficient communication/poor relationships between care settings. Within a hospital HF program at one site, good communication and coordination may occur while the patient is in the hospital. Communication may also be effective with the outpatient cardiac rehabilitation programs. However, the relationship between the primary care provider and the treating cardiologist/specialty center varies from very collaborative and communicative to independent and even adversarial. It is important to recognize the existing relationships and differences between transitions to different settings.

• Lack of incentives for coordination of care. There are few incentives for traditional, fee-for-service

“Communication is probably one of the biggest issues during transitions of care – various electronic health records, multiple providers, not knowing whom to speak with, not initiating or closing the gaps in communication, not being able to have the providers available at the same times, and few opportunities when all of the stakeholders are in a room together.” – Kelley Anderson, PhD, FNP, CHFN-K



systems to effectively coordinate care, although some of the newer models, such as accountable care organizations (ACOs), as well as the components of value-based care are encouraging this more.

Clinician-Level Barriers

• Breakdowns in communication between providers/teams. Breakdowns in communication between providers and care teams can occur, especially for patients with HF who receive care in multiple settings due to comorbidities and complex management. Multiple clinicians often provide care to a single patient, all of whom may modify the care plan and medications, with or without communication to the other providers. Polypharmacy is often a challenge for patients with HF. In addition, it can be challenging for clinicians to apply overlapping, and sometimes contradictory guidelines (‘dueling guidelines’) for the multiple conditions experienced by each patient.

• Breakdowns in communications with patients/caregivers. Breakdowns in communication occur not only between providers, but also with patients and their family caregivers. Although communication may be improving between providers and patients on clinical issues, it is often the nonclinical issues, such as health literacy, transportation, or caregiver availability, that may not have been assessed appropriately and affect transitions of care.

• Poor adherence. Patients may struggle with adherence to medications and dietary restrictions. Contributors to non-adherence in HF patients include complications from comorbidities and other clinical constraints (eg, low blood pressure, low heart rate, renal dysfunction), uncertainty about the care plan, and errors in taking the medications as prescribed, particularly when polypharmacy and multiple medication changes by multiple providers occur.46 Due to inadequate understanding and lack of consolidation strategies, patients prescribed multidrug regimens several times a day often complicate the dosing. This results in missed or incorrectly administered doses, thereby enhancing concerns of medication safety and non-adherence.47

• Lack of understanding of the next care setting. Many providers function within a system and are not aware of other systems or settings, including the home setting. In some cases, order sets may be written that cannot be applied in the next care setting.

Patient-Level Barriers

• Lack of engagement. Patients are not always engaged in their care or provided with the tools for shared decision making. They may not fully understand the quality of life issues or how to communicate their preferences and personal treatment goals. There are many treatment options (e.g., medications, ICDs, biventricular pacing, LVADs, heart transplant, intravenous inotropes) and it is important for patients, or their decision-makers where needed, to be knowledgeable about the roles of these interventions and when they may or may not be appropriate.

• Patient education – prognosis. Patients may not be aware of the trajectory of their illness, what to expect over time, and the risks and benefits of different options. A higher level of care or hospitalization may not always be the most appropriate strategy.

• Financial constraints and navigating insurance. Some patients may not be able to afford their medications or gain approval from their health plan. If the hospital physician is unavailable, the local physician may be asked to help, but may not have the information needed to explain why a more expensive medication is being prescribed and if there has been a trial of a lesser cost or plan formulary medication first.

“Poor communication may lead to safety issues, wasted resources, and redundant testing.” – Kelley Anderson, PhD, FNP, CHFN-K



• Health literacy. Health literacy or cognitive issues may be underappreciated in patients, resulting in care instructions not being understood or enacted. Patients may not understand the benefits and risks of medications or recognize warning signs (or “red flags”) that may indicate their health condition is worsening, such as an increased body weight. Patients struggle with pronouncing the names of their medications, let alone understanding their regimen or side effects. Supporting patients to implement their care plans means providers must recognize not only the patient’s health literacy, but confirm what language is their primary language. Where cognitive issues are noted, determination of patient capacity is essential, with inclusion of appropriate decision-makers in the care plan discussions.

• Patient uncertainty. Determining what questions to ask and how to engage the care team can be a challenge for patients. Patients may lack the awareness, knowledge, and self-management skills for implementing the care plan, including medication management.

• Social determinants. A lack of understanding may exist among the care team around social issues such as financial concerns, transportation, home care responsibilities of even more frail patients upon return, health plan coverage barriers, and other impediments to implementation of the care plan. Patients may face lack of transportation or financial challenges in obtaining their medications. Patients and their families/caregivers may have concerns on providing meals or support for the patient at home due to the caregiver having a full-time job. In some cases, patients do not have a caregiver and are left to self-manage all the care issues. Cultural, language, and ethnic concerns may also be a barrier to patient engagement and adherence.

• Psychosocial issues. Psychosocial issues can compound care transitions. A study assessing unmet needs of patients in cardiac rehabilitation revealed that patients struggle with a variety of psychosocial complications including lack of motivation to leave home, anxiety related to shortness of breath or fear of heart attack or stroke, frustration, depression, not feeling well, lack of family/caregiver support, difficulty managing work around the house, and adherence to medication.48

Benefits of Continuity of Care

Continuity of care is the quality of care provided over time, the importance of which is now recognized by many national healthcare organizations, including the Agency for Healthcare Research and Quality (AHRQ), National Quality Forum (NQF), National Transitions of Care Coalition (NTOCC), and the Joint Commission.49 Care coordination is an integral part of the continuity of care. AHRQ describes care coordination as “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer, more effective care.”50

Better continuity of care is associated with lower risk for inpatient hospitalization, ER visits, and complications, leading to reduced healthcare costs and improved patient outcomes.51 In randomized trials of 749 patients in an urban hospital setting in Boston, discharge services, such as follow-up appointment assistance, medication reconciliation, and patient education, decreased ER visits and 30-day hospital readmissions by 30%.52 In other studies, the use of “transition coaches” and advanced practice nurses to help coordinate care, provide continuity across settings, and to encourage patients and caregivers to engage in a more proactive role during care transitions has also been shown to reduce re-hospitalization rates.53,54 For patients with HF, potential benefits of continuity of care may include improved stamina and confidence to work to an older age, participate in family life, and actively participate in their own care and self-management.

“Patients and families often don’t know what to ask, or cannot recall information that is provided to them, because it may not have been communicated in a manner that the patient can understand or retain.” – Kelley Anderson, PhD, FNP, CHFN-K



Outcomes Expected from Implementation of These Recommendations

This white paper, focused on improving care transitions for patients with HF, identifies and emphasizes the following key areas within NTOCC’s “7 Essential Intervention Categories:”

• Medication Management: applying systematic approaches to medication reconciliation of the medication list

• Transition Planning: using formal transition planning tools such as discharge checklists and processes to initiate discharge planning upon admission

• Patient and Family Engagement/Education: health literacy and providing appropriate, tailored education to patients and families/caregivers at care transitions

• Information Transfer: timely, appropriate, bi-directional communication between care settings

• Follow-up Care: Prompt post-discharge follow-up scheduled for the patient prior to discharge

• Healthcare Provider Engagement: Using evidence-based, guideline-directed treatment and management of HF based on patient characteristics (e.g., LVEF) and recognizing patients approaching the end stage of HF and implementing palliative care

• Shared Accountability Across Providers and Organizations. Ensuring the care plan is feasible for the next care setting and assigning specific care team members or positions to perform them.

Anticipated outcomes of this paper include more consistent application of evidence-based guideline-directed care in HF; improved patient understanding of, engagement in, and adherence to the care plan; increased number of patients who receive their prescribed medications and complete a post-discharge follow-up appointment; enhanced communications between providers and care settings; and appropriate implementation of palliative care. It is expected that these improvements will lead to safer care transitions, improved patient experience and engagement, reduced hospital readmissions, and improved quality of life for patients with HF.

CONSIDERATIONS IN HEART FAILURE TRANSITIONS OF CARE

Tools to Facilitate Transitions of Care in Heart Failure

Although research has been conducted to identify gaps in care and contributors to re-hospitalizations in HF and general tools have been developed to support providers and patients in the management of HF, comprehensive tools specifically designed for the multidisciplinary team to facilitate transitions of care for patients with HF are lacking. Included in the appendices of this care pathway are 3 new tools to bridge this gap: (1) NTOCC’s “7 Essential HF Care Transition Interventions,” (2) NTOCC’s “Taking Care of My HF Health Care,” a tool for patients that includes a medicine list template, and (3) a sample Letter to Healthcare Providers to support transfer of information regarding the HF patient’s status, treatment, and management requirements. A copy of this letter can be provided not only to the receiving provider, but also to the patient and caregiver as a tool to empower patients and caregivers in navigating care transitions.

Care Setting Commitment

Commitment from senior leadership in the care setting is essential to implement system-level processes for effective transitions of care.55 Consistently visible support from senior leadership removes barriers and provides oversight/accountability, ethical commitment, resources/training, and facilitates system-wide engagement. The business case to achieve care setting commitment is driven by the need to reduce medical errors; improve adherence to national quality measures and ethical standards to favorably affect value-based payments; prevent drug adverse events; decrease re-hospitalizations; and improve patient outcomes and safety. Establishment of quality measures and regular data collection is useful to demonstrate the positive impact of transition improvements on the care setting to ensure continued support.



Leadership support is a critical factor for sustainability of care transition intervention programs.56 Key factors that facilitate care setting commitment and promote sustainability include:57

• Low resource requirements

• Customization to the care setting

• Alignment with the care setting’s mission, objectives, and routines

• Presence of a program champion who promotes sustainability

Leaders can promote a system-wide transformation by infusing change throughout the care processes, highlighting urgency, setting direction, sharing expectations, and providing resources.58 These are key elements for sustaining successful transition of care long-term programs.

Patient and Family/Caregiver Engagement and Education in Transitions of Care

• Clear understanding of diagnosis and prognosis. Despite the difficult nature of these discussions, it is important for patients to have a good understanding of the disease, their particular condition, and the disease trajectory. Although there is no cure, more people are surviving with HF. In particular, patients should understand the difference between reduced and preserved ejection fraction, which type of HF they have, and how that impacts which options are likely to provide a benefit to them. Heart transplants may be an option for some patients, but with people living longer with HF, they may not always be accessible or appropriate. Equipped with this information, patients can have productive conversations with their providers. Having a realistic understanding of the options can impact treatment decisions, interventions (devices, heart transplant), financial decisions, and end-of-life considerations.

• Shared treatment decision making. Patients need to understand the importance of their input and engagement and participate as much or as little as they choose. Time should be spent to educate patients and families to ensure that they are knowledgeable about their illness and the available therapeutic options. Equipped with this knowledge, the patient and family/caregiver can actively participate in development of an individualized care plan with their healthcare team. To implement their care plan, patients need awareness, knowledge, and self-management skills.59

• Patient/caregiver education. It is essential to educate patients and families/caregivers on self-care, lifestyle modifications, and adherence to treatment and monitoring regimens. Cultural, ethnic, and religious issues need to be considered. What is the primary language of the patient and the caregiver? Are there challenges with medication adherence? Does the patient have transportation to attend appointments and pick up prescriptions? Are ‘home remedies’ being used? Are there challenges with maintaining a low sodium diet? Sometimes caregivers are not willing to cook different meals for the patient. Is there more than one caregiver? If so, how do they communicate?

• Information/communication. Meaningful communication and education are essential for smooth care transitions. Sometimes, patients are provided with too much information. Education should be targeted, tailored, and relevant to the patient and the care plan should be clear. A member of the care team needs to be designated to take ownership of three key issues – (1) communication with the healthcare team at the next care setting (2) patient education and (3) medication reconciliation – at each care transition.



• Medication counseling. It is important for patients to know what each medication does, why they are taking it, and what the primary side effects are. Not only does this information prepare patients as they transition between different health settings and different providers, it helps engage the patients in their care plan and promotes adherence. It should also be verified that the patient has a way to obtain and afford newly prescribed medications. Does the patient have transportation? Can the patient read and understand the instructions?

• Adherence. Importance of adherence to treatment plan. Are the patient and caregiver confident in carrying out the care plan?

• Side effects and recognizing and responding to emergencies. Patients and caregivers need to know what signs/symptoms indicate a need for additional care, the level of care to obtain, and whom to contact. It is especially important for patients and caregivers to quickly recognize emergency situations that require immediate care. Education and a written emergency plan can help patients distinguish between when to call a member of their care team and when to go to the ER.60

4 Questions that Patients Need to Ask About Their Medications:

1. What is the name of the medication?

2. What does it do?

3. Why do I need to take it?

4. What are the potential side effects?

Table 2. Essential HF Care Transitions Intervention: Patient and Family/Caregiver Education and Engagement

Ensure patients and families/caregivers are knowledgeable about HF and have a plan of care they can understand and implement

• Assess health literacy and gaps in the patient’s and family’s/caregiver’s knowledge of HF, and their understanding of how to be independent in managing their medications; recognize that health literacy may differ significantly between patients and caregivers

• Check patient’s and family’s/caregiver’s understanding of “red flags” for HF symptom escalation and whom they need to contact for support (eg, a written emergency plan)

• Facilitate interaction with social workers, home health, and community staff to provide coaching and counseling for coping and self-management

Patient- and family-centered transition communication:

• Use a coordinated, multidisciplinary approach to patient and family/caregiver communication ensuring that the care team, patient, and family/caregiver are understanding the same language/information

• Adapt communications with HF patients and families/caregivers based on health literacy and appropriate language is essential

• Support dialogue on advance care planning and the needs of the patient and family/caregiver

• Provide face-to-face discussions with patients and families/caregivers to eliminate miscommunication

Develop self-care management skills:

• Assess patient’s and family’s/caregiver’s ability to manage their medication and treatment therapies and develop the care plan around that assessment

• Provide opportunity for appropriate patient teach-back and discussion of risk issues

• Develop a nutrition plan, with consideration for sodium and fluid intake, with the patient and family/caregiver assessing concerns related to cultural, financial, and social burden

• Goal of asking and supporting patients and families/caregivers to take responsibility for monitoring their own healthcare needs on a daily basis (including measuring and recording body weight daily), maintaining an up-to-date medication list, and how and when to seek appropriate assistance when needed

HF = heart failure.



Working With the Interprofessional Team in Transitions of Care

Interprofessional Roles

Role of the Primary Care Team (PCP, Medical Home, Nurse Practitioners, Physican Assistants, others as involved)

• The PCP should be the ‘nexus’ for the HF care team that advises and oversees the HF care plan to bring together the social and financial considerations, advance directives, and family/caregiver perspectives to create a personalized, patient-centered plan of care. The PCP should reinforce the key messages of the care plan and coordinate with healthcare professionals at each care setting to ensure that the care plan is applied as patients are transitioned.

Role of the General Cardiologist/Cardiology Providers

• The local cardiologist should stay up-to-date with current guidelines for HF, transitions of care, and chronic care management and educate and update the clinical community on HF.

• Communicate effectively with the primary care team

• Refer to the HF specialist as indicated

• Obtain specialty and sub-specialty consultations (e.g., electrophysiology) as indicated, including referrals for advanced HF therapies

• Educate and activate the patient and family/caregiver

Role of the HF Specialist

• The HF specialist should coordinate and be accessible to the local cardiologist and other members of the interdisciplinary team when needed.

• Maintain knowledge on advancements in HF care and promote and follow evidence-based guidelines

• Communicate effectively with the cardiologist


• Partner with the hospital care team and care continuum team as necessary to sustain quality of care for HF patients as they enter other sites of care during their course of disease, and experience decline in clinical status

Role of Additional Specialists (e.g., electrophysiology specialist, comorbidities)

• Additional specialists should stay up-to-date with current guidelines for HF, transitions of care, and chronic care management

• Communicate effectively with the referring care team


Role of the Pharmacist

• Provide a leadership role in medication management and medication reconciliation for individuals with HF

• Be a resource to the interdisciplinary team and patient on the proper use of medication, their benefits and risks

• Provide information to support patient engagement in their care. They should also identify and manage medication-related issues, including polypharmacy.

• Eliminate unnecessary and inappropriate medications



• In addition to patient education, pharmacists may be involved in post-discharge calls and counseling, identification/resolution of re-hospitalization risk factors, optimization of medical therapy, communication with community physicians and pharmacists, and home visits. Active involvement of pharmacists in these types of interventions has been shown to increase patient adherence and exercise ability and decrease re-hospitalizations, clinical events, and mortality.61

• It cannot be overstated how dynamic formularies are for each setting, resulting in a change in care setting that may prompt changes in medication. Patients may be directed to change certain medication when they move to skilled care and then medications may change again when they move to long-term care and are dual-eligible. There are many different brands of medications, as well as generic formulations. A pharmacist is best positioned to oversee the overall pharmacologic plan, recognize everything on the medication list, and distinguish between old and new prescriptions.

• Key roles for pharmacists in care transitions62-64

» Medication selection, optimization, prevention of drug interactions for medications for HF as well as for comorbid conditions

» Medication reconciliation at care transitions

» Ongoing medication therapy monitoring

» Participate in multidisciplinary rounds

» Patient/caregiver education, including safety/side effect counseling

» Participate in discharge, including patient interviews, follow-up on medication-related issues, evaluate and address adherence

» Post-discharge follow-up within 2-4 days

» Collaborate on medication reconciliation with long-term care facilities and other sites of care upon transitions

» Communicate with community pharmacists, including resolving discrepancies and reviewing auto-refills post-discharge

» Collaborate with home health care pharmacists and agencies

» Provide pharmacy services in ambulatory care settings

» Provide services to address adherence, access, and health literacy

Role of Nurses, Social Workers, Case Managers, and other Allied Health Professionals

• Nurses and social workers are key in all levels of care experienced by patients with HF, including acute, urgent, skilled nursing facilities, home health, etc. In addition to hands-on patient care, these healthcare professionals are integral to ensure appropriate education, shared decision making, and teaching of patients and caregivers about HF, lifestyle modifications (including diet, exercise), self-management, and assessment for changes in symptoms, and should be available for the patient and family to address questions and concerns. Nurses provide care by evaluating clinical and nonclinical issues, including medical and behavioral. Patients may communicate with these healthcare providers, including nurses and social workers, in a more open manner than other professionals. Bi-lateral communication with team members and accountability for ensuring appropriate follow up and transfer of information are essential.

• Case managers play an important role in the management of HF patients and incorporation of case management has been shown to reduce re-hospitalization and mortality in patients with HF.65 Case managers should assess and understand the health literacy level of each patient and caregiver, assist their patients in creating and maintaining a medication list, and ensure that transitions are coordinated with sending and receiving care teams. They should assess the home situation including the support system and challenges to



implementation of the care plan. Case managers play a key role in supporting patients with implementing and adhering to a care plan and life-care planning and patient advocacy are key roles for these providers. The information that is gathered should be shared across the continuum of care and it should be confirmed that the patient and family caregiver have an understanding of the various levels of care for patients with HF.

Role of the Patient Navigator

• Professional Patient Navigators, employed to help patients overcome barriers and access appropriate care,66 have increased their role in HF management. In recent years, patient navigators have been taking on an increasing role in the management of patients with HF. In a program developed by the American College of Cardiology, 30-day hospital readmissions were reduced by 81.3% (4.8% vs. 25.6%; p=0.0003) when nurse and pharmacist navigator teams provided education, therapy recommendations, and 14-day follow up to patients with HF customized to their health literacy and social needs.67

Role of the Community Health Worker

• The Centers for Disease Control and Prevention (CDC), recognizes the important role of Community Health Workers in HF management in the CDC resource, “A Community Health Worker Training Resource for Preventing Heart Disease and Stroke.”68 Specific ways Community Health Workers can support patients with HF include:68

» Emphasize the importance of adherence to medication regimens and teach practical strategies for keeping track of medications

» Support patients in obtaining cardiac rehabilitation (if advised by the physician)

» Help patients recognize symptoms that indicate a need to call their provider or go to an emergency room

» Assist patients in acquiring a scale so they can record their weight daily

» Work with nutritionists or dieticians to teach patients how to follow a low sodium diet (e.g., how to prepare low sodium meals) and manage fluid intake as recommended by their physician, manage stress and depression, and integrate appropriate exercise

» Encourage patients in lifestyle changes such as smoking cessation, weight loss, and minimizing alcohol consumption

» Provide resources to support caregivers

Role of the Hospitalist

• To ensure a smooth transition upon discharge, the hospitalist should generate the medication list then direct and assist the nurse to provide tailored education to the patient/caregiver and confirm understanding of the new care plan.

• It is essential that hospitalists understand and consider the next care setting when developing the new care plan, including limitations that may impact the feasibility of certain medication regimens or follow up tests. For example, CT scans may not be available and transportation difficult in long-term care and, therefore, may need to be conducted prior to transition.

• Hospitalists can help bridge care transitions by visiting and providing for follow up education in the new care setting, ideally within 48 hours.

Role of the Post-Acute Care Specialist

• To ensure a smooth transition between hospital discharge to the skilled nursing facility, inpatient rehabilitation facility or long-term acute care hospital, then to the upcoming patient environment.

• The post-acute care specialist should generate the medication list, then direct and assist the nurse to provide tailored education to the patient/caregiver and confirm understanding of the new care plan.



• It is essential the post-acute care specialists understand and consider the next care setting when developing the new care plan, including limitations that may impact the feasibility of certain medication regimens or follow up tests. For example, finances and availability of follow up services may not be available in the home site of care, and transportation difficult or unavailable there.

• Post-acute care specialists can help bridge care transitions by overseeing site-adjusted education for the new care setting, directing faculty personnel to determine useful local resources and, as appropriate, contacting clinicians in the next care setting to facilitate the transition of information.

Role of Home Health Provider

• Healthcare providers in the home setting may be registered nurses (RNs), licensed practical nurses (LPNs), physical therapists (PTs), occupational therapists (OTs), speech language pathologists (SLPs), home health aides (HHAs), medical social workers (MSWs), and a variety of other allied health workers.

• Home health services require an order by a physician for implementation

• The goal of home care is to allow the patient to remain at home rather than placement in a residential, long-term, or institutional-based nursing care.

• For the HF patient, two primary home health services are to provide patient and family/caregiver education and monitoring of this serious illness and unstable health status.

Role of Cardiac Rehabilitation

• Although it is an important intervention, cardiac rehabilitation is often underutilized. The addition of HF with reduced ejection fraction (but not preserved ejection fraction) as an eligible diagnosis for cardiac rehabilitation payment by the CMS should make this a more accessible opportunity for eligible patients.69 Healthcare professionals, such as nurse case managers, should discuss this option with the care team and then discuss with the patient the advantages of the program if it is approved by the team. Discussions should include an emphasis on the need to adhere to the program to receive the benefits. Cardiac rehabilitation provides physical and occupational therapy, self management exercises, and care skills to improve the quality of life for patients with HF, including improved ambulation.70 For patients who strongly adhere to the program, cardiac rehabilitation may help patients gain confidence in their ability to exercise, which can reduce fatigue, improve breathing, prevent hospital admissions, and improve overall quality of life. However, clear benefit for cardiac rehabilitation has not yet been established for all patients with HF, such as those with preserved ejection fraction or left ventricular assist devices (LVADs).70

Role of the Patient

• Patients should know they are part of their HF care team and understand the important role they play in managing their health and care plan. Patients and caregivers are the only constant as the patient moves through multiple care settings throughout the course of this chronic disease. Their role must be encouraged and supported. Patients should: (1) identify themselves as a HF patient to each new provider, (2) provide the name and contact information for their cardiologist or cardiovascular provider, and (3) communicate any additional diagnoses (comorbidities) they may have. They must be the keepers of the patient history, medications used (the effects

“Home health care is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility (SNF).” – CMS Website.

www.medicare.gov/what-medicare-covers/home-health-care/home-health-care-what-is-it-what-to-expect.html. Accessed 10/12/17.

3 Questions that Patients Need to Ask About

1. What are my options?

2. What are the benefits and risks?

3. What happens if I do nothing?



and side effects), tests performed and results, advance directives, patient wishes, and knowing their clinicians and specialists. Patients and caregivers should also be equipped with the knowledge and skills to recognize and communicate to providers and care systems when a change in status occurs. Throughout the course of care, it is imperative for both patients and caregivers to know when to seek help and ask questions, advocate for the patient’s wishes, and understand, be engaged in, and adhere to the care plan. There should be very clear goals for treatment and interventions. Three questions that patients should ask are:

• What are my options?

• What are the benefits and risks?

• What happens if I do nothing?

Role of the Caregiver

• Participate in educational sessions preceding a change in care setting

• Support the patient in adhering to the care plan, including the medication regimen and dietary restrictions

• Recognize signs/symptoms that necessitate a phone call or emergency care

• Act as an advocate for the HF patient

Interprofessional Communication and Collaboration

• Referral to specialty centers

• Clinicians should reach across sites of care to interact directly with the interprofessional team » Timely communication is essential. Some interventions have to be

done within a certain period of time. If there is a delay and the patients decompensate, the options for the patient become limited.

» Bi-directional communication is key

• Chronic Care Management (CCM) payment codes » CCM may be billed most frequently by primary care practitioners, although

in certain circumstances, specialty practitioners may provide and bill for CCM

» Only one practitioner may be paid for CCM services for a given calendar month

» Three Current Procedural Terminology (CPT) codes are available for billing services:

i. CPT 99490 – Chronic Care Management Services

ii. CPT 99487 – Complex Chronic Care Management

iii. CPT 99489 – add on code to Complex Chronic Care Management

» CCM services may be provided by clinical staff under the direction of the billing provider as an “incident to” basis. Clinical staff are either employees or working under contract to the billing practitioner whom Medicare pays directly for CCM.

» Patients eligible for this service must have multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.71

Patient Role in Medication Management:

1. Take a list of current medications, including what each medication is prescribed for and who prescribed it - OR -

2. Take a plastic bag with all of the actual prescription bottles – every medication from every doctor

3 Things HF Patients Need to Tell Their Next Provider:

1. I am a Heart Failure patient

2. My cardiologist is . . .

3. I’ve also been diagnosed with ...



Table 3. Essential HF Care Transitions Intervention: Healthcare Provider Engagement

Clearly identified patient’s primary care team

• Primary care provider – each patient has an ongoing relationship with a primary care team trained to provide first contact, continuous, and comprehensive care (eg, patient-centered medical home model)

• Enhanced access to services and provision of follow-up appointments without long wait times

• Refer HF patients to cardiology specialty care and HF expert care centers as appropriate

• Communicate a change in care site to the patient’s HF expert care center

• Ability and willingness to collaborate with HF expert care centers and appropriate other regional HF care sites to perform community care (including hospital and care continuum as appropriate) for HF patients. This includes:

» Notifying HF expert care centers of changes in condition » Regularly communicating with HF expert care centers on patient status » Implementing changes in care plan as directed by HF expert care centers

Clearly identified patient’s HF expert care center team

• Provide community outreach and education to improve HF recognition, diagnosis, and care

• Partner with the community primary care team in the care of HF patients to allow quality HF care to be maintained in the community setting (some settings may have a designated heart failure or transitions of care pharmacist)

• Partner with the hospital care team and care continuum team as necessary to sustain quality care for HF patients as they enter other sites of care during the course of their disease and as they experience decline in clinical status

Clearly identified patient’s hospital and care continuum team

• Refer HF patients to HF expert care centers as appropriate

• Ability and willingness to collaborate with HF expert care centers and appropriate other regional HF care sites to deliver quality care for HF patients during the hospital stay. This includes:

» Notifying HF expert care centers of changes in condition » Implementing changes in care plan as directed by HF expert care centers » Referral back to the HF expert care centers as needed » Communicating with HF expert care centers on patient status as indicated

Use of recognized HF practice guidelines (evidence-based guidelines)

• Reconciliation of the discharge or transition plan with national HF guidelines and critical pathways

• Implementation of evidence-based HF guidelines as well as other appropriate care tools and plans

Hub of case management activities

• Improve documentation around any change in patient’s (or resident’s) condition

• Improve flow of information between hospital, care continuum, community primary care team, and HF expert care team on hospital and ER admissions

• Being a communication hub

• Shared decision making including patient values, goals, informed preferences, and concerns

• Reconcile pre- and post-hospitalization medications lists in concert with the HF expert care center team as appropriate

Patient and family/caregiver education and counseling activities

• Coaching patients on self-care management with attention to “red flags” (signs/symptoms that indicate a need for additional care) in concert with the HF expert care team education efforts

• Giving, or facilitating, the patient and family/caregiver to receive a written discharge or transition plan and instructions at the time of discharge/transition

• Transmitting the discharge/transition plan and instructions to the HF expert care team for review and feedback

Open and timely communication among healthcare providers, patients, and families/caregivers

• Enhanced communication with other healthcare providers in the HF continuum of care about change in a patient’s (or resident in some settings) status

• Close interaction between care coordinators, hospitalists, community primary care team, and HF expert care team

• Care is coordinated and/or integrated by coordinating patient care in a team-based approach

ER = emergency room; HF = heart failure.



Shared Accountability

Shared accountability across providers and care settings is also essential to facilitate effective interprofessional communication and collaboration to coordinate care for patients with HF (Table 4). This involves clear and timely communication of the care plan across care transitions, ensuring continuity of care with the sending provider remaining responsible for the patient’s care until the receiving provider has acknowledged that he/she can effectively assume the care, and assuming responsibility for the outcomes of the care transitions.

Transition Planning• Hospital discharge – assess readiness for discharge

» Incorporate interdisciplinary team rounds prior to discharge

» Did we address the problem the patient came in with?

» Have we addressed how the problem will be avoided in the future?

» Are there other underlying issues that need to be addressed7,8, such as

i. Significant comorbidities (e.g., uncontrolled hypertension, arrhythmias, progressive coronary artery disease, renal failure, COPD)

ii. Acute issues (e.g., pneumonia)

iii. Social issues (e.g., nonadherence to medication or treatment plan, fall assessment or independence assessment necessary)

Table 4. Essential HF Care Transitions Intervention: Shared Accountability Across Providers and Care Settings

Clear and timely communication of the patient’s plan of care to the patient and receiving provider as well as between the HF expert care center, primary care team, and all sites of care as the patient moves between various sites of care

• Healthcare provider must communicate plan of care to patient and receiving provider before handoff is completed

• The sending provider must be available to the receiving provider for any questions and clarifications regarding the patient’s care after the handoff

• Notify the receiving entity of the patient diagnosis of HF, that specialty care is involved, and the need to involve the HF expert care center as appropriate

• Inform the receiving entity of the contact information for the patient’s treating HF expert care center

• Notify the primary care provider within 48 hours of a care transition60

Ensuring that a healthcare provider is responsible for the care of the patient at all times

• Sending healthcare provider must remain responsible for the patient’s care until the receiving provider has acknowledged that he/she can effectively assume the care of the HF patient

• The receiving provider has to acknowledge the receipt of transferred information in a timely manner, understand the plan of care for the patient or contact the sending site with questions, and be prepared to assume responsibility for patient’s care

Assuming responsibility for the outcomes of the care transition process by all relevant healthcare providers (the provider [or organization] sending the patient, the one receiving the patient, and those engaging the HF expert care center as appropriate)

• If the provider who has assumed care of the patient determines that a different level of care is needed, the provider is responsible for communicating the change in plan back to the other providers and the HF care team

• Be involved in the patient’s transition safety and outcomes report, utilizing quality indicators including HF-associated indicators

HF = heart failure.

Essential Pre-Discharge Questions for the Patient:

Ask:

1. Why were you in the hospital?

2. What medications are you on?

3. What are the warning signs that indicate you need to call your health care team (e.g., increase in body weight)?

4. Who do you call and how?



• Hospital discharge – transfer care back to primary care provider and primary cardiology team » Continue heart failure program. It should be communicated to other providers that the patient is in a

heart failure program. The providers, as well as the patients and caregivers, must be equipped with the education and resources to sustain or effectively transition the program after the patient is discharged from the hospital.

• Hospital discharge – support patient’s transition back home » Ensure patients have a follow up appointment scheduled within 7-14 days (monitor heart failure and

comorbidities, which are also key drivers of hospital readmissions)

» Educate patients to record weight daily

» Emphasize importance of adhering to the medication regimen and diet recommendations

» Provide a reconciled list of medications

» Check for understanding using the teach-back technique. Do you understand why you were in the hospital? How comfortable are you in understanding how to take your medications when you get home?

• Transfer from primary care to expert center (or vice versa)

• Transition to long-term care/nursing home/hospice » Acute care team should contact long-term care ahead of time to notify the center of the patient’s arrival

and of any uncommon medications that may require additional planning. Many times, patients are transferred on off hours including weekends, holidays, etc. when key team members are not available and these details are more challenging to evaluate.

Table 5. ACCF/AHA Hospital Discharge Recommendationst20

At discharge + follow-up visits, the following should be ad-dressed:

• Initiation/optimization of guideline-directed medical therapy as appropriate

• Underlying causes of HF, barriers to care, and limita-tions in support

• Adjustment of HF therapy based on volume status and blood pressure

• Renal function and electro-lyte status

• Management of comorbid-ities

• Patient education (HF, self-care, recognizing and responding to emergency, adherence)

• Palliative or hospice care

For patients at high risk for re-hospitalization: multidis-ciplinary HF disease-manage-ment programs

Follow-up visit within 7-14 days of dischargeTelephone follow-up within 3 days of discharge

Use clinical risk prediction tools and/or biomarkers to identify high-risk patients

ACCF = American College of Cardiology Foundation; AHA = American Heart Association; HF = heart failure.



Table 6. Essential HF Care Transitions Intervention: Transition Planning

Clearly identify the interdisciplinary care team members (primary care provider, HF specialist, consulting clinicians, nurse, social worker, case manager, home care specialist, pharmacist allied health professionals and community staff, and patient/caregiver) and coordinate the patient’s transition plan

• Use of a HF specialty nurse, social worker or case manager who conducts a comprehensive assessment of the patient’s and family/caregiver’s clinical and nonclinical needs, including knowledge deficit, health literacy, financial, social, self-management skills, and mental health needs

• Conduct an interdisciplinary team case conference to set the transition plan and coordinate the plan with the patient and family/caregiver. It is recommended that the patient and family/caregiver be included in the case conference.

• Ensure a risk assessment has been performed to identify patients who may benefit from specialized interventions, including advanced therapies and home care

• Post-transition, the care team needs to conduct a follow-up visit/call/electronic portal intervention to review care needs, health status, and coordination issues shortly after facility discharge

• Pharmacist will call the patient post-transition to assess understanding of medication regimen

• Identify community suppliers of medical equipment and specialty medications that will be available to the patient upon discharge

• Communicate with the HF expert care center when transitioning site of care

Management of the HF patient’s and family’s/caregiver’s transition needs

• Evaluate left ventricular function

• Manage fluid overload

• Ensure underlying issues have been addressed, such as hypertension, arrhythmias, coronary artery disease, pneumonia, renal failure, chronic obstructive pulmonary disease (COPD), and adherence to diet and medications

• Enhanced assessment of physical activity and supervised rehabilitation

• Creation of a patient care plan that supports the tasks and interventions being asked of the patient and family/caregiver in managing their HF

• Encourage patients and their families to join patient support groups

• Psychosocial coaching and counseling support to coordinate the psychological, social, financial, emotional, and spiritual functioning of the patient and family/caregiver, including smoking cessation counseling where appropriate

• Proactive advanced care planning with referral to specialist palliative care services when appropriate

Use formal transition planning tools (providers, patients, and families/caregivers)

• From the hospital: Project BOOST® or Project Re-Engineered Discharge (Project RED) » Project BOOST® is a national initiative led by the Society of Hospital Medicine to improve the care transition from

the hospital to the home setting. Expert mentors and peer support help hospitals improve system-level care transition processes.72

» Project RED is an AHRQ initiative to improve hospital discharge processes via a Re-Engineered Design (RED) toolkit.73

• ACC/AHA/HFSA Guideline for the Management of Heart Failure and AHA’s Scientific Statement “Transitions of Care in Heart Failure”

• Collaborative team care plan through the use of an EHR from one level of care, setting, or provider to another where available

• NTOCC patient resource guideline for a hospital stay

Timely and completed transition summary

• Completed transition summary inclusive of all transition care needs and recommendations by the transition team

• Should be received by the receiving site prior to, but at the latest, at the time of transition to the receiving facility

• Transmitted in a format/method appropriate for the receiving site (electronic, phone call, paper, etc.) and requiring bilateral communication of acceptance from the next level of care

• The transitioning team should ensure the patient and family/caregiver have a written copy of the transition plan at the time of transition, that they understand the information, and feel confident they can follow through with the self-management skills required

AHRQ = Agency for Healthcare Research and Quality; BOOST = Better Outcomes by Optimizing Safe Transitions; EHR = electronic health record; HF = heart failure; NTOCC = National Transitions of Care Coalition.



Medical Records and Information Transfer

Medication Reconciliation and Drug Interaction Prevention

• Medication reconciliation should be done at every care transition. Formulary, out-of-pocket costs, and what the patient should actually receive should all be considered when making medication decisions and changes.

• In addition to reconciling medications at every transition of care, an accurate medication list should be created to accompany the patient to the next care setting. Thought should be given to financial and cognitive abilities, medication availability, and social issues, such as transportation, when optimal treatment regimens are determined with individual patients.

• Patient-centered strategies for medication management and to improve patient adherence include: » Creation of a patient-centric medication list that is understandable by the patient and family/caregiver

» Meds-to-beds programs’ that provide medications to patients at the bedside prior to discharge

» Personalized medication packs organized by morning, noon, evening, and bedtime (following Universal Medication Schedule framework)

» On-site pharmacy in the hospital setting to fill prescriptions

» Bedside counseling and assessment of understanding of medication regimen

» Post-discharge follow-up phone call to review medication regimen and understanding

• Drug interaction risk reduction

• Ensure all pharmacy systems have the patients complete medication list to allow for computer screening for significant drug interactions

• Be aware that patients are at high risk for therapeutic duplication during transitions due to formulary changes

Table 7. Essential HF Care Transitions Intervention: Medical Records and Information Transfer

Implementation of clearly defined communication models

• Use of multidisciplinary care teams and case conferences including the patient and family/caregiver

• Bi-directional communication, which requires not only sending the information but acknowledgement from the receiving care team that they received the information, understand the information, and possess the ability to provide continuity of the transition plan and care plan

• A designated person and their contact information is indicated by the sending care site to respond to questions by the receiving site

• Clear communication models that recognize the need for using appropriate health literacy and language with the patient and family/caregiver

Use of formal communication tools

• Use of personal health records/portals

• Implementation of standardized HF communication tools within an organization’s EHR or web-based management systems plus a defined process for sharing information when HIT is not available

• Assess the appropriateness of mobile apps for patients and families/caregivers in support of medication management and follow-up care options

Clearly defined providers, care centers, and community resources to facilitate timely transfer of critical information

• Appropriate transfer of information to a HF expert care center when applicable, including diagnostic testing results, advance care planning information, and previous disease-targeted therapies

• The ability to conduct real-time patient-centered/family-centered “hand-over” communication facilitates consistency of information sharing

EHR = electronic health record; HF = heart failure; HIT = health information technology.



WHO has included “Assuring Medication Accuracy at Transitions of Care: Medication Reconciliation” as a core element in its “High 5s” patient safety collaborative project.55 Based on the tenets of this program, the following algorithm describes recommended practices for medication reconciliation in individuals with HF.

Figure 3. Medication Reconciliation Process in Individuals with HF

BPMH = best possible medication history; BPMDP = best possible medication discharge plan; HF = heart failure.

Table 8. Essential HF Care Transitions Intervention: Medication Management

Assessment of patient’s medications intake

• Medication review, including OTC medications, herbals, vitamins, allergies, and drug interactions

• Identify medication-related problems, such as tolerability

• Assess adherence and access to medications, particularly specialty pharmacy medications

• Assess ability to administer medications and access to resources to facilitate access to specialty medications for the treatment of HF

Patient and family/caregiver education and counseling about medications

• Teach-back method to establish understanding of medication plan

• Explain what medication to take, emphasizing any changes in the regimen and rationale for changes

• Review each medication’s purpose, how to take or administer each medication correctly, and important side effects to watch for

• Discuss special resource needs based on medications prescribed

Development and implementation of a plan for medication management as a part of the patient’s overall plan of care

• Provide medication reconciliation including pre-hospitalization or facility and post-hospitalization or facility medication list

• Distribute medication reconciliation pre- and post-admission lists to all sites of care utilized beyond the patient’s usual community residence

• Discuss processes for accessing and maintaining supply of specialty pharmacy or compounded medications

• Confirm the medication plan and follow-up care plan

• Consider post-hospitalization or post-facility follow-up phone call or visit in home for continuity of care as a best practice

• Interaction between cardiologist, HF specialist and community care providers regarding HF and other medications with any change in clinical status or medications

HF = heart failure; OTC = over-the-counter.



Support and Follow-Up Care

In an analysis of the impact of follow-up interventions on hospital readmissions, the US Department of Health and Human Service’s (DHHS) AHRQ details that home-visits, outpatient clinic-based multidisciplinary HF programs, and structured telephone support reduced re-hospitalizations and mortality over 3-6 months following the initial hospitalization, highlighting the importance of follow-up care.74

Advance Care Planning• Advance care planning is a discussion with the patient and, when appropriate, the family/caregiver about

the care the patient would want to receive if they become unable to speak for themselves. This includes the explanation and discussion of advance directives such as standard forms by the physician or other qualified health professional face-to-face with the patient, family members, and/or surrogate. In 2016, CMS provided payment codes for voluntary Advance Care Planning, CPT codes 99497 and 99498.

Table 9. Essential HF Care Transitions Intervention: Follow-Up Care

HF patients and families/caregivers require timely access to key healthcare providers after an episode of care as required by the patient’s condition and needs

• Patients and families/caregivers need confirmation of their care team members including their primary care physician, HF specialist, nurse, social work educator or case manager, home health nurse, and other interprofessional staff

• The patient and family/caregiver are informed of which provider to call and contact information is provided, for problems or questions during the transition

• Community staff and resources need to be defined and roles between the clinical team and community resources documented on the patient care plan

• A follow-up appointment within 7-14 days after a hospital transition, or sooner if clinically indicated, should be made prior to leaving the hospital

• Review with the patient and family/caregiver the follow-up care plan and need for adherence to the plan

Communication with patients and/or families/caregivers and other healthcare providers post-transition from an episode of care

• An HF nurse specialist to call patients and families/caregivers within 24-72 hours after transition from the hospital to assess any post-transition care needs including medication therapies, diet, daily measurement of body weight, monitoring for recurrent congestion, and comorbidities

• Aggressively manage recurrent congestion using non-hospital options

• Additional follow-up call in 2-3 days after the above call to reinforce the transition and care plan, confirm ability to recognize “red flags” that signal a need to call or seek additional care, and resolve any miscommunication or care concerns

• Schedule a home visit from a nurse or social work case manager if appropriate to review medication therapies and management, exercise training, social well-being, mental health, help the patient troubleshoot problems and contact healthcare providers when needed

• Re-assessment of the patient’s care plan and goals of care; schedule regular contact times with the patient and family/caregiver

• Ensure patients and families/caregivers understand how to detect changes in medical, functional, behavioral, and psychosocial problems, and know whom to contact

• Possible referral to an HF expert care center for assessment and treatment plan

• Frequent communication with the HF care team members either telephonically, EHRs, patient portals, or face-to-face

• Coordinating provider may use the Medicare Chronic Care Management codes for reimbursement of appropriate ongoing monitoring and care coordination with their HF patients

EHRs = electronic health records; HF = heart failure.



• Initiating end-of-life conversations can be difficult and advance care planning discussions are often delayed. However, these conversations should occur early in the course of care as patients and families/caregivers often relay that they wished they had these earlier. For example, discussions about implanting an ICD should include a conversation about when is an appropriate time to turn this off. The existing paradigm is to intervene because there is much that can be done for cardiovascular illnesses. However, there is little benefit in end-stage HF and even if there is an intervention available, patients should be asked, “Do you want this intervention?” There is difficulty in acceptance and denial on all sides – providers, patients, and families. Patients and caregivers may not be aware of the options and patients with HF may be referred to palliative care and hospice too late.

• One problem with implementing palliative care is prognostication in HF. It can be easy to identify patients for whom end of life is approaching soon, but much more difficult to identify those further out, especially due to the fluctuating nature of the clinical decline. The American Heart Association has addressed this need in their 2012 statement, “Decision Making in Advanced Heart Failure.”59 Often the recognition that oral therapies are failing signals the transition to advanced HF and ushers in a change of the patient’s goals. At this time, if transplantation and mechanical circulatory support are not appropriate, then consideration should be given to initiating palliative care. The Heart Failure Society of America Guidelines Committee has defined advanced HF as, “the presence of progressive and/or persistent severe signs and symptoms of heart failure despite optimized medical, surgical, and device therapy.”43 Prompt recognition of these signs in HF patients can trigger timely decisions on whether additional therapy will benefit the patient or if it is time to pursue palliative care (Table 10).

2015 Heart Failure Society of America Advanced (Stage D) Heart Failure definition: (Fang et al., 2015)

“The presence of progressive and/or persistent severe signs and symptoms of heart failure despite optimized medical, surgical, and device therapy. It is generally accompanied by frequent hospitalization, severely limited exertional tolerance, and poor quality of life and is associated with high morbidity and mortality. Importantly, the progressive decline should be primarily driven by the heart failure syndrome.”

Table 10. Signals of advanced heart failure include

Laboratory/Clinical Indicators

Functional Indicators

Event Indicators

Peak VO2 <14 mL kg-1 min-1 or <50% of predicted

Need for intravenous inotropic therapy >2 HF admissions in <12 months

Persistent hyponatremia (serum sodium <134 mEq/L)

6-minute walk distance <300 meters>2 emergency visits (ER or clinic) in <12 months

Cardiac cachexiaWorsening right HF and secondary pul-monary hypertension

Increased 1-yr mortality (eg, 20-25%) estimated by HF survival models

Refractory to diuretics associated with declining renal function

Recurrent refractory ventricular tachyar-rhythmias or frequent ICD shocks

Circulatory-renal limitation to RAAS inhi-bition or beta-blocker therapy

Inability to perform activities of daily living

Progressive/persistent NYHA functional class III-IV symptoms

Progressive renal or hepatic end-organ dysfunction

*Adapted from Fang JC, Ewald GA, Allen LA. Advanced (Stage D) Heart Failure: A Statement From the Heart Failure Society of America Guidelines Committee. J Card Fail. 2015;21(6):519-534.43



IMPLEMENTATION OF A CARE TRANSITION PROGRAM A Care Transition Pathway for HF

Patients with HF go through many transitions, often including multiple hospitalizations with multiple providers managing different aspects of care, throughout the course of their disease (Figure 4). Care settings should establish formal processes for management of care transitions to promote safe transitions and reduce 30-day hospital readmissions or patients with HF (Figure 5).

Figure 4. Care Transitions Throughout Heart Failure

HF = heart failure; PCP = primary care physician.

Figure 5. A Heart Failure Care Transition Pathway



Quality Measures and Assessment of Care Transition Management

Finally, care setting performance in managing care transitions should be assessed. This is an increasing area of focus with the enactment of the Patient Protection and Affordable Care Act (PPACA) and the development of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Care Transition Measure that determines patients’ care transition experiences following an inpatient hospital stay, including how well patients understood the type of care they would need after discharge.75-77

In 2008, the NTOCC Measures Work Group identified several considerations for care transition measures, including:78

• At every patient visit: document the patient’s “hub of care” and permission to share information with other providers/care settings

• Ensure procedures are in place to confirm and document that essential information (eg, medication list) has been sent to the intended receiving provider/care setting

• Ensure procedures are in place to confirm and document that essential information has been received by the intended provider/care setting

• Document and review that care coordination activities facilitated by the “care coordination hub” are appropriate and necessary.

In 2012, the NQF endorsed 12 quality measures to assess care coordination and transitions of care that can be utilized by care settings to evaluate their performance (Table 11):79

Table 11. NQF-Endorsed Care Coordination Measures79

Measure Description

0097 Medication reconciliation (NCQA)

0171 Acute care hospitalization (risk-adjusted; CMS)

0173 Emergency department use without hospitalization (CMS)

0326 Advance care plan (NCQA)

0494 Medical home system survey (NCQA)

0526 Timely initiation of care (CMS)

0553 Care for older adults – medication review (NCQA)

0554 Medication reconciliation post-discharge (NCQA)

0646 Reconciled medication list received by discharged patients* (AMA-PCPI)

0647 Transition record with specified elements received by discharged patients* (AMA-PCPI)

0648 Timely transmission of transition record* (AMA-PCPI)

0649 Transition record with specified elements received by discharged patients** (AMA-PCPI)

*Discharges from an inpatient facility to home/self-care or any other site of care **Emergency department discharges to ambulatory care (home/self-care) or home health care. NQF = National Quality Forum; NCQA = National Committee for Quality Assurance; CMS = Centers for Medicare and Medicaid Services; AMA = American Medical Association; PCPI = Physician Consortium for Performance Improvement.



In 2011, the ACCF/AHA/AMA-PCPI published measures specific to HF, including measures to assess activities related to transitions of care (Table 12):80

SUMMARYSignificant progress has been made in the management of HF in recent years. New therapeutic options, including ivabradine and the combination product of valsartan and sacubitril, have reduced the risk for hospitalization and improved patient outcomes for patients with HF with reduced ejection fraction. However, options are still limited for HF patients with preserved ejection fraction.

Despite these therapeutic advances, HF is most often, a chronic, incurable progressive disease and patients with HF experience multiple transitions and providers throughout the course of their disease. HF care teams must anticipate and plan for these transitions by implementing system-based care transition pathways to facilitate safe transitions and reduce inappropriate hospitalizations. Management of HF is complex and often patients with HF experience multiple comorbidities, and therefore is it essential to follow evidence-based guidelines, consider referral to an expert HF care center when possible, secure care setting commitment, and engage the multidisciplinary team along with the patients and their families/caregivers in the development and execution of a patient-centered care plan. Timely, bi-directional communication and information transfer at transition points is essential. Careful consideration must be given to ensure the care plan can be carried out and the prescribed medications will be available in the next care setting. Providers must ensure that patients and their families/caregivers understand and are equipped to carry out the care plan and providers should follow up promptly to verify successful transition. Advance planning conversations should be initiated early on to document a medical power of attorney and end-of-life care. Care transition procedures should be evaluated on an ongoing basis.

This white paper outlined pathways for safe care transitions for patients with HF throughout the course of disease to reduce re-hospitalizations and improve patient outcomes and experiences of care.

Table 12. ACCF/AHA/AMA-PCPI-Endorsed 2011 Heart Failure Measures: Transitions of Care Activities80

Measure Description

Patient self-care education

Percentage of patients aged >18 years diagnosed with HF who were provided with self-care education on >3 elements of education during >1 visits within a 12-month period.

Post-discharge appointment

Percentage of patients, regardless of age, discharged from an inpatient facility to ambulatory care or home health care with a principal discharge diagnosis of HF for whom a follow-up appointment was scheduled and documented, including location, date, and time for a follow-up office visit or home health visit.



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RESOURCES

Appendix I. Additional Resources

Heart Failure Information

• American Heart Association: www.heart.org

• Centers for Disease Control and Prevention: www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure

• Heart Failure Society of America: www.hfsa.org

• American Association of Heart Failure Nurses: www.aahfn.org

• American College of Cardiology: www.acc.org

Patient Support Groups

• AHA Heart Failure Support Network: https://supportnetwork.heart.org/

Caregiver Support Groups

• Caregiver Action Network: www.caregiveraction.org

• Family Caregiver Alliance: www.caregiver.org

Transitions of Care Resources

• National Transitions of Care Coalition: www.ntocc.org

• The Visiting Nurse Associations of America Blueprint for Excellence: www.vnaablueprint.org

• The Visiting Nurse Associations of America Guide for Artful Conversations: www.vnaablueprint.org/hospice-palliative/artful-conversations/artful-conversation.html

Advance Directive and End-of-Life Planning Tools

• Aging with Dignity: 5 Wishes: www.agingwithdignity.org

• Physician Orders for Life-Sustaining Treatment Paradigm (POLST): www.polst.org

• Respecting Choices: www.gundersenhealth.org/respecting-choices

BE SURE YOU KNOW THESE THINGS:1. Why am I meeting with a healthcare provider today? ___________________________________

2. What medical conditions do I have? __________________________________________________

__________________________________________________________________________________

3. What other healthcare providers have I seen since my last visit? __________________________

4. Have my medications changed since my last visit? ______________________________________

5. Do I have a list of all the medicines I need to take, including all on the following list? Important: Tell the healthcare provider any allergies or sensitivities you have to any medicine.

___ Prescription medicine (can buy only with a prescription)

___ Over-the-counter medicine (can buy without a prescription)

___ Vitamins, herbs, or supplements I take (such as St. John’s Wort)

___ Any new prescriptions I received during this visit

___ Written directions on how to take all my medicines

___ Major side effects of these medicines

6. Besides taking my medicines, what else do I need to do?

___ Get blood tests or other medical tests?

___ Get extra help or equipment at home?

___ Avoid caffeine, alcohol, tobacco, or other drugs?

___ Eat or avoid eating certain foods?

___ Change a bandage?

___ Exercise?

7. Name of HF Expert Care Center: ________________ Phone Number: ___________________

Contact Person at the HF Care Center: _____________________________________________

8. When were you last seen by your HF Care Center: ___________________________________

___ Were there changes in your medications at that visit: Yes___ No___

___ If there were changes, what were they: _________________________________________

9. Name of Cardiologist (Heart Specialist): ____________________ Phone: ___________

10. Which doctor or other healthcare provider will I see next and why? ____________________

________________________________ How soon? ____________________________________

How do I make an appointment?__________________________________________________

11. Has my doctor sent a copy of my discharge plan or other information about my health (including all my medicine and other treatments) to my next healthcare provider or facility? MAY I HAVE A COPY OF THAT INFORMATION TODAY? _________________________

12. What tests were done today? _________________

13. Who should I call before my next appointment if I have questions or problems managing my care or dealing with my HF? _________________________________________________

Take this with you each time you meet with a healthcare provider (such as a doctor, nurse, pharmacist, or social worker); visit an emergency room, hospital, nursing center, or other healthcare facility; or receive care in your home. You have rights to your personal health information. Using this guide can help you keep track of your health information and may prevent other health problems.

Adapted from NTOCC’s MY Health Care @ NTOCC.org.

Being sick can affect all areas of your life. If you have questions or concerns about any of the following, check the box and talk about them with a healthcare provider.

NAME:_________________________ PHONE: _________________

Visit With:__________________

Today’s Date:_______________

ON THE FOLLOWING PAGE IS SPACE TO WRITE DOWN YOUR MEDICINES, QUESTIONS, AND CONCERNS TO TAKE WITH YOU TO YOUR NEXT DOCTOR’S VISIT

A guide for you or your caregiver to be active in either your own health care or caring for someone else.

� Advance care planning � Alcohol, drug, or tobacco use � Caregiving concerns � Changes in behavior, memory,

or thinking � Cultural/religious customs

affecting health care � Financial or insurance � Home safety � Medical equipment needs;

help with walking, bathing, eating, or dressing

� Relationships/intimacy concerns

� Taking medicines � Transportation and driving

issues � Understanding my illness or

conditions � Increasing tiredness and

shortness of breath

!

Appendix II. Taking Care of My HF Health Care

WHEN I GET UP, I TAKE:

IN THE AFTERNOON, I TAKE:

IN THE EVENING, I TAKE:

BEFORE I GO TO BED, I TAKE:

OTHER MEDICINES THAT I DO NOT USE EVERYDAY:

Drug name -brand name

or generic & DOSE

This looks like?

color, shape

How many?

How I take it

I started taking this on: (date)

I stopped taking this on: (date)

Why I take it

Who told me

to take it(name)

Example:Lisinopril 10 mg

Round yellow pill

1By mouth with

breakfastJune 3, 2008 Keep taking

High blood pressure

Dr. Smith

QUESTIONS I WANT TO TALK ABOUT WITH MY HEALTHCARE PROVIDER AT MY NEXT VISIT:

Adapted from NTOCC’s MY Health Care @ NTOCC.org.



APPENDIX III. LETTER TO HEALTHCARE PROVIDERSThe following letter template is designed to support communication between healthcare providers regarding the care of patients with HF. A copy of this letter (printed on your organization’s letterhead) can be provided to the receiving care provider as well as the patient and family/caregiver to facilitate communication during a care transition. The language of the letter, including bold and bracketed text, should be replaced with patient-specific information and customized for your practice.

[Date]

[Name of Addressee]

[Address]

Re: [Patient’s Name]

Date of Birth: [Patient Date of Birth]

Insurance or Other ID Number: [Patient ID Number]

To Whom It May Concern:

I am writing on behalf of my patient, [Patient Name], to communicate information regarding their current medical diagnosis, condition, and treatment regimen. Further, I wish to highlight special considerations related to their diagnosis and treatment.

[Patient Name] has been diagnosed with Heart Failure (HF). The diagnosis was made in [Month, Year] and [he/she] has been under my care since [Month, Year].

Currently, the patient’s HF is considered to be ACC/AHA Stage [A, B, C, or D]. The patient’s most recent NYHA functional class assessment was [I, II, III, or IV] and the most recent LVEF was [___%]. The patient [does/does not] have an ICD. The patient [does/does not] not have CRT.

The patient’s HF is currently treated with [list current therapy here]. This agent can result in [list significant common side effects]. Unless absolutely contraindicated, this agent should be continued as prescribed, without any lapses in therapy or missed doses.

The patient’s HF is complicated by the following comorbidities [list comorbidities here].

Thank you for your assistance in the care of this patient. Please let me know if you require additional information or if I can be of any assistance.

Sincerely,

[Signature]

[Provider’s Name]

[Providers’s Contact Information]



Appendix IV. 7 Essential HF Care Transition Interventions

Essential Intervention Categories

DescriptionExamples of Transition

Care Intervention

1. Medication Management

Ensuring the safe and effective use of medications by patients with HF, including those with comorbidities, and their family/caregiver:

• Assessment of patient’s medication intake, adherence to the medication regimen, and tolerability

• Patient and family/caregiver education and counseling about medications

Development and implementation of a plan for medication management as part of the patient’s overall plan of care

Assessment of patient’s medications intake

• Medication review, including OTC medications, herbals, vitamins, allergies, and drug interactions

• Identify medication-related problems, such as tolerability

• Assess adherence and access to medications, particularly specialty pharmacy medications

• Assess ability to administer medications and access to resources to facilitate access to specialty medications for the treatment of HF

Patient and family/caregiver education and counseling about medications

• Teach-back method to establish understanding of medication plan

• Explain what medication to take, emphasizing any changes in the regimen and rationale for changes

• Review each medication’s purpose, how to take or administer each medication correctly, and important side effects to watch for

• Discuss special resource needs based on medications prescribed

Development and implementation of a plan for medication management as a part of the patient’s overall plan of care

• Provide medication reconciliation including pre-hospitalization or facility and post-hospitalization or facility medication list

• Distribute medication reconciliation pre- and post-admission lists to all sites of care utilized beyond the patient’s usual community residence

• Discuss processes for accessing and maintaining supply of specialty pharmacy or compounded medications

• Confirm the medication plan and follow-up care plan

• Consider post-hospitalization or post-facility follow-up phone call or visit in home for continuity of care as a best practice

• Interaction between cardiologist, HF specialist and community care providers regarding HF and other medications with any change in clinical status or medications

HF = heart failure; OTC = over-the-counter

APPENDIX IV. 7 ESSENTIAL HF CARE TRANSITION INTERVENTIONS



Appendix V. 7 Essential HF Care Transition Interventions (cont.)



Care Intervention

2. Transition Planning

A formal process that facilitates the safe transition of HF patients from one level and site of care to another, including home or from one practitioner to another:

• Clearly identify the provider and care centers (acute, post-acute, and community-based) to facilitate and coordinate the patient’s transition plan

• Ensure the multidisciplinary care team manages the patient’s and family’s/caregiver’s transition needs

• Use of formal transition planning tools

• Development and completion of a transition summary (discharge plan)

Clearly identify the interdisciplinary care team members (primary care provider, HF specialist, consulting clinicians, nurse, social worker, case manager, home care specialist, pharmacist allied health professionals and community staff, and patient/caregiver) and coordinate the patient’s transition plan

• Use of a HF specialty nurse, social worker or case manager who conducts a comprehensive assessment of the patient is and family’s/caregiver’s clinical and nonclinical needs, including knowledge deficit, health literacy, financial, social, self-management skills, and mental health needs

• Conduct an interdisciplinary team case conference to set the transition plan and coordinate the plan with the patient and family/caregiver. It is recommended that the patient and family/caregiver be included in the case conference.

• Ensure a risk assessment has been performed to identify patients who may benefit from specialized interventions, including advanced therapies and home care

• Post-transition, the care team needs to conduct a follow-up visit/call/electronic portal intervention to review care needs, health status, and coordination issues shortly after facility discharge

• Pharmacists will call the patient post-transition to assess understanding of medication regimen

• Identify community suppliers of medical equipment and specialty medications that will be available to the patient upon discharge

• Communicate with the HF expert care center when transitioning site of care

Management of the HF patient’s and family’s/caregiver’s transition needs

• Evaluate left ventricular function

• Manage fluid overload

• Ensure underlying issues have been addressed, such as hypertension, arrhythmias, coronary artery disease, pneumonia, renal failure, chronic obstructive pulmonary disease (COPD), and adherence to diet and medications

• Enhanced assessment of physical activity and supervised rehabilitation

• Creation of a patient care plan that supports the tasks and interventions being asked of the patient and family/caregiver in managing their HF

• Encourage patients and their families to join patient support groups

• Psychosocial coaching and counseling support to coordinate the psychological, social, financial, emotional, and spiritual functioning of the patient and family/caregiver including smoking cessation counseling where appropriate

• Proactive advanced care planning with referral to specialist palliative care services when appropriate






Care Intervention

2. Transition Planning (cont.)

Use formal transition planning tools (providers, patients, and families/caregivers)

• From the hospital: Project BOOST® or Project Re-Engineered Discharge (Project RED)

» Project BOOST® is a national initiative led by the Society of Hospital Medicine to improve the care transition from the hospital to the home setting. Expert mentors and peer support help hospitals improve system-level care transition processes. (www.hospitalmedicine.org/boost)

» Project RED is an AHRQ initiative to improve hospital discharge processes via a Re-Engineered Design (RED) toolkit (www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.htm)

• ACC/AHA/HFSA Guideline for the Management of Heart Failure and AHA’s Scientific Statement “Transitions of Care in Heart Failure”

• Collaborative team care plan through the use of an EHR from one level of care, setting, or provider to another where available

• NTOCC patient resource “Guideline for a Hospital Stay”

Timely and completed transition summary

• Completed transition summary inclusive of all transition care needs and recommendations by the transition team

• Should be received by the receiving site prior to, but at the latest, at the time of transition to the receiving facility

• Transmitted in a format/method appropriate for the receiving site (electronic, phone call, paper, etc.) and requiring bilateral communication of acceptance from the next level of care

• The transitioning team should ensure the patient and family/caregiver have a written copy of the transition plan at the time of transition, that they understand the information, and feel confident they can follow through with the self-management skills required

AHRQ = Agency for Healthcare Research and Quality; BOOST = Better Outcomes by Optimizing Safe Transitions EHR = electronic health record; NTOCC = National Transitions of Care Coalition





Care Intervention

3. Patient and Family/Caregiver Engagement and

Education

HF education and counseling of patients and families/caregivers to enhance their active participation in their own care, including informed decision-making:

• Patients and families/caregivers are provided appropriate education

• Patient and family/caregiver-centered transition communication

• Development of self-care management skills

Ensure patients and families/caregivers are knowledgeable about HF and have a plan of care they can understand and implement

• Assess health literacy and gaps in the patient’s and family’s/caregiver’s knowledge of HF, and their understanding of how to be independent in managing their medications; recognize that health literacy may differ significantly between patients and caregivers

• Check patient’s and family’s/caregiver’s understanding of “red flags” for HF symptom escalation and whom they need to contact for support (eg, a written emergency plan)

• Facilitate interaction with social workers, home health, and community staff provide coaching and counseling for coping and self-management

Patient- and family-centered transition communication

• Use a coordinated, multidisciplinary approach to patient and family/caregiver communication ensuring that the care team, patient, and family/caregiver are understanding the same language/information

• Adapt communications with HF patients and families/caregivers based on health literacy and appropriate language is essential

• Support dialogue on advance care planning and the needs of the patient and family/caregiver

• Provide face-to-face discussions with patients and families/caregivers to eliminate miscommunication

Develop self-care management skills

• Assess patient’s and family’s/caregiver’s ability to manage their medication and treatment therapies and develop the care plan around that assessment

• Provide opportunity for appropriate patient teach-back and discussion of risk issues

• Develop a nutrition plan, with consideration for sodium and fluid intake, with the patient and family/caregiver assessing concerns related to cultural, financial, and social burden

• Goal of asking and supporting patients and families/caregivers to take responsibility for monitoring their own healthcare needs on a daily basis (including measuring and recording body weight daily), maintaining an up-to-date medication list, and how and when to seek appropriate assistance when needed





4. Medical Records and Information

Transfer

Sharing of important information among the patient, family/caregiver, and healthcare providers in a timely and effective manner:

• Implementation of clearly defined communication models

• Use of formal communication tools

• Clearly defined providers to facilitate timely transfer of information

Implementation of clearly defined communication models

• Use of multidisciplinary care teams and case conferences including the patient and family/caregiver

• Bi-directional communication, which requires not only sending the information but acknowledgement from the receiving care team that they received the information, understand the information, and possess the ability to provide continuity of the transition plan and care plan

• A designated person and their contact information is indicated by the sending care site to respond to questions by the receiving site

• Clear communication models that recognize the need for using appropriate health literacy and language with the patient and family/caregiver

Use of formal communication tools

• Use of personal health records/portals

• Implementation of standardized HF communication tools within an organization’s EHR or web-based management systems plus a defined process for sharing information when HIT is not available

• Assess the appropriateness of mobile apps for patients and families/caregivers in support of medication management and follow-up care options

Clearly defined providers, care centers, and community resources to facilitate timely transfer of critical information

• Appropriate transfer of information to a HF expert care center when applicable, including diagnostic testing results, advance care planning information, and previous disease-targeted therapies

• The ability to conduct real-time patient-centered/family-centered “hand-over” communication facilitates consistency of information sharing

AHRQ = Agency for Healthcare Research and Quality; EHR = electronic health record; NTOCC = National Transitions of Care Coalition






Care Intervention

5. Follow-Up Care Facilitating the safe transition of HF patients from one level of care to another through effective follow-up care interventions:

• Patients and families need timely access to key healthcare providers after an episode of care as required by the patient’s condition and needs

Communicating with patients/families and other healthcare providers post-transition from an episode of care

HF patients and families/caregivers require timely access to key healthcare providers after an episode of care as required by the patient’s condition and needs

• Patients and families/caregivers need confirmation of their care team members including their primary care physician, HF specialist, nurse, social work educator or case manager, home health nurse, and other interprofessional staff

• The patient and family/caregiver are informed of which provider to call and contact information is provided, for problems or questions during the transition

• Community staff and resources need to be defined and roles between the clinical team and community resources documented on the patient care plan

• A follow-up appointment within 7-14 days after a hospital transition, or sooner if clinically indicated, should be made prior to leaving the hospital

• Review with the patient and family/caregiver the follow-up care plan and need for adherence to the plan

Communication with patients and/or families/caregivers and other healthcare providers post-transition from an episode of care

• An HF nurse specialist to call patients and families/caregivers within 24-72 hours after transition from the hospital to assess any post-transition care needs including medication therapies, diet, daily measurement of body weight, monitoring for recurrent congestion, and comorbidities

• Aggressively manage recurrent congestion using non-hospital options

• Additional follow-up call in 2-3 days after the above call to reinforce the transition and care plan, confirm ability to recognize “red flags” that signal a need to call or seek additional care, and resolve any miscommunication or care concerns

• Schedule a home visit from a nurse or social work case manager if appropriate to review medication therapies and management, exercise training, social well-being, mental health, help the patient troubleshoot problems and contact healthcare providers when needed

• Re-assessment of the patient’s care plan and goals of care; schedule regular contact times with the patient and family/caregiver

• Ensure patients and families/caregivers understand how to detect changes in medical, functional, behavioral, and psychosocial problems, and know whom to contact

• Possible referral to an HF expert care center for assessment and treatment plan

• Frequent communication with the HF care team members either telephonically, EHRs, patient portals, or face-to-face

• Coordinating provider may use the Medicare Chronic Care Management codes for reimbursement of appropriate ongoing monitoring and care coordination with their HF patients






Care Intervention

6. Healthcare Provider

Engagement

Demonstrating ownership, responsibility, and accountability for the care of the patient and family/caregiver at all times:

• Clearly identified patient’s primary care team

• Clearly identified patient’s HF expert care center team

• Clearly identified patient’s hospital and care continuum team

• Use of recognized, evidence-based practice guidelines

• Hub of case management activities

• Patient and family/caregiver education and counseling activities

Clearly identified patient’s primary care team

• Primary care provider – each patient has an ongoing relationship with a primary care team trained to provide first contact, continuous, and comprehensive care (eg, patient-centered medical home model)

• Enhanced access to services and provision of follow-up appointments without long wait times

• Refer HF patients to cardiology specialty care and HF expert care centers as appropriate

• Communicate a change in care site to the patient’s HF expert care center

• Ability and willingness to collaborate with HF expert care centers and appropriate other regional HF care sites to perform community care (including hospital and care continuum as appropriate) for HF patients. This includes:

» Notifying HF expert care centers of changes in condition » Regularly communicating with HF expert care centers on

patient status » Implementing changes in care plan as directed by HF

expert care centers Clearly identified patient’s HF expert care center team

• Provide community outreach and education to improve HF recognition, diagnosis, and care

• Partner with the community primary care team in the care of HF patients to allow quality HF care to be maintained in the community setting (some settings may have a designated HF or transitions of care pharmacist)

• Partner with the hospital care team and care continuum team as necessary to sustain quality care for HF patients as they enter other sites of care during the course of their disease and as they experience decline in clinical status

Clearly identified patient’s hospital and care continuum team

• Refer HF patients to HF expert care centers as appropriate

• Ability and willingness to work with HF expert care centers and appropriate other regional HF care sites to deliver quality care for HF patients during the hospital stay. This includes:

» Notifying HF expert care centers of changes in condition » Implementing changes in care plan as directed by HF

expert care centers » Referral back to the HF expert care centers as needed » Communicating with HF expert care centers on patient

status as indicated






Care Intervention

6. Healthcare Provider

Engagement (cont.)

Use of recognized HF practice guidelines (evidence-based guidelines)

• Reconciliation of the discharge or transition plan with national HF guidelines and critical pathways

• Implementation of evidence-based HF guidelines as well as other appropriate care tools and plans

Hub of case management activities

• Improve documentation around any change in patient’s (or resident’s) condition

• Improve flow of information between hospital, care continuum, community primary care team, and HF expert care team on hospital and ER admissions

• Being a communication hub

• Shared decision making including patient values, goals, informed preferences, and concerns

• Reconcile pre- and post-hospitalization medications lists in concert with the HF expert care center team as appropriate

Patient and family/caregiver education and counseling activities

• Coaching patients on self-care management with attention to “red flags” (signs/symptoms that indicate a need for additional care) in concert with the HF expert care team education efforts

• Giving, or facilitating, the patient and family/caregiver to receive a written discharge or transition plan and instructions at the time of discharge/transition

• Transmitting the discharge/transition plan and instructions to the HF expert care team for review and feedback

Open and timely communication among healthcare providers, patients, and families/caregivers

• Enhanced communication with other healthcare providers in the HF continuum of care about change in a patient’s (or resident in some settings) status

• Close interaction between care coordinators, hospitalists, community primary care team, and HF expert care team

• Care is coordinated and/or integrated by coordinating patient care in a team-based approach

ER = emergency room






Care Intervention

7. Shared Accountability

Across Providers and Organizations

Enhancing the transition of care process through accountability of care for the patient by both the healthcare provider (or organization) transitioning and the one receiving the patient:

• Clear and timely communication of the patient’s plan of care

• Ensuring that an engaged, appropriate healthcare provider is responsible for the care of the patient at all times

• Assuming responsibility for the outcomes of the care transition process by both the provider (or organization) sending, the one receiving the patient, and engaging the HF expert care center as appropriate

Clear and timely communication of the patient’s plan of care to the patient and receiving provider as well as between the HF expert care center, primary care team, and all sites of care as the patient moves between various sites of care

• Healthcare provider must communicate plan of care to patient and receiving provider before handoff is completed

• The sending provider must be available to the receiving provider for any questions and clarifications regarding the patient’s care after the handoff

• Notify the receiving entity of the patient diagnosis of HF, that specialty care is involved, and the need to involve the HF expert care center as appropriate

• Inform the receiving entity of the contact information for the patient’s treating HF expert care center

• Notify the primary care provider within 48 hours of a care transition

Ensuring that a healthcare provider is responsible for the care of the patient at all times

• Sending healthcare provider must remain responsible for the patient’s care until the receiving provider has acknowledged that he/she can effectively assume the care of the HF patient

• The receiving provider has to acknowledge the receipt of transferred information in a timely manner, understand the plan of care for the patient or contact the sending site with questions, and be prepared to assume responsibility for patient’s care

Assuming responsibility for the outcomes of the care transition process by all relevant healthcare providers (the provider [or organization] sending the patient, the one receiving the patient, and those engaging the HF expert care center as appropriate)

• If the provider who has assumed care of the patient determines that a different level of care is needed, the provider is responsible for communicating the change in plan back to the other providers and the HF care team

• Be involved in the patient’s transition safety and outcomes report, utilizing quality indicators including HF-associated indicators



Learning Objectives

� Apply evidence-based and expert consensus strategies for closing critical gaps in HF care transitions and coordination

� Describe current evidence and updated guidelines for the pharmacologic management of patients with HF

� Develop comprehensive hospital discharge and home-based care plans that account for individualized needs of patients with HF

� Implement evidence-based and expert consensus strategies for interprofessional collaborative practice to address needs of patients with HF and comorbidities

� Apply evidence-based and expert consensus strategies for patient-centered HF care, including patient/caregiver education, shared decision-making, self-care and self-monitoring, and adherence promotion

There is no fee for this activity as it is sponsored by PRIME through an educational grant from Novartis Pharmaceuticals.

ACCREDITATION STATEMENTSIn support of improving patient care, PRIME® is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the

Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 2.0 Interprofessional Continuing Education (IPCE) credits for learning and change.

Physician Credit Designation Statement PRIME® designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credit™. Physicians should claim only credit commensu-rate with the extent of their participation in the activity. Physician Assistant Accreditation Statement AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME. Physician assistants may receive a maximum of 2.0 hours of Category I credit for completing this program.

Pharmacist Accreditation Statement This curriculum has been approved for 2.0 contact hours (0.2 CEUs) by PRIME®. PRIME® is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. The Universal Activity Number for this program is 0255-0000-17-062-H01-P. This learning activity is Knowledge-based. Your CE credits will be electronically submitted to the NABP upon successful completion of the activity. Pharmacists with questions can contact NABP customer service ([email protected]).

Nurse Accreditation Statement PRIME® designates this activity for 2.0 contact hours.

Case Manager Accreditation Statement The Commission for Case Manager Certification designates this educational activity for 2.0 contact hours for certified case managers.

Instructions to obtain credit:

1. Complete the activity in its entirety.

2. Visit PRIME®’s Credit Center at www.primeinc.org/credit.

3. Enter program code 24PR171.

4. Upon completion of the learner assessment tools, you will be able to print your certificate.

Monograph Release Date: November 1, 2017 | Expiration Date: October 31, 2017

AN INTERDISCIPLINARY GUIDE FOR SAFER CARE ......5 of 46 2017 o Interdisciplinary Guide for Safer...

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