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Five keys to creating a CHF disease management program

HCPRO Website, February 11, 2013

February is the month dedicated to the heart, but it is about more than just Valentine's Day. Each year, the American Heart Association dedicates the month of February to heart health awareness and prevention.

CHF is one of the most prevalent chronic and progressive diseases that homecare agencies deal with, and it is a leading cause in hospital admissions. Over five ­million Americans live with heart failure, and about one in five people who have heart failure die within one year of diagnosis. CHF has many causes, including coronary artery disease, diabetes, and hypertension. Early diagnosis and treatment can improve the quality and expectancy of life for people with heart failure. People with heart failure should also track their daily ­symptoms and vital signs and discuss them with their doctors. Homecare clinicians play an important role in encouraging patient compliance and focusing attention on environmental and lifestyle factors. If an agency has a high rate of patients with CHF, it is crucial for it to develop a disease management program.

The components of a CHF disease management program should be simple and patient-centered. Remember that this is a suggestion of what should be included; the program can change based on patient population.

Key components of the program will include:

  • An emergency care plan. At the start of care, all CHF patients should have an emergency care plan implemented. This tool can be adapted to most diagnoses and should be tailored to meet each patient's needs. Once this care plan has been initialized, the patient, caregiver, and/or family should be educated on its use. The emergency plan should be placed in a location that is easily accessible (e.g., refrigerator) in the patient's home. It is important to educate patients and their caregivers on the signs and symptoms of a worsening condition and whom to notify. Early recognition of symptoms is paramount in preventing rehospitalization.
  • CHF disease management tool. Disease management programs and tools do not have to be complicated and costly to be effective. Use of zone tools can aid your agency in disease management for little cost.
  • Patient-friendly medication list. Regardless of what format you choose, the medication list should be filled out at the start of care and be kept updated by the clinician. It should contain allergies, names and strengths of medications, what the medication is used for, dosage (including how often and/or what time), special instructions, and refill/end dates. The list should contain all medications, including over-the-counter and herbal remedies. Remember, this list is for your patient to use.
  • Teaching and tracking sheets, plus a disease-specific care plan. Tracking tools that can be utilized for CHF include diet, disease process, and complications. They can be used while coaching the patient and left in the home for future reference. Patients should have trackers for vital signs and weight. Disease-specific care plans can aid clinicians by providing a road map for care and ensuring that all of the patient's needs are met.
  • Communication templates. Templates are very helpful for clinicians and physicians. They assist clinicians in providing the right information in a concise and consistent manner. Templates help physicians discard useless information and meet their expectations with the information they need to make decisions.

Together, these items will form a disease management program for CHF that is neither costly nor difficult. In the interest of making it easy for your clinicians to comply, package these items together so that when clinicians initiate a program, they can grab the packet and go. Many other tools can be included depending on the patient and the disease, but the tools above are crucial to any disease management program. A program targeted for CHF will ensure healthier hearts for your patients in February and beyond.

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