Heart Failure: Transitions of Care

Source: CMSA Today


Even though our healthcare system has focused on heart failure for several years, we continue not to see the outcome results sought. Readmission rates and medication reconciliation continue to be hot topics when discussing heart failure outcome data. Although these are important measures to consider, I think there is much more to consider. For example, some of the readmissions that are preventable are due to the lack of weight monitoring across the transitions of care, including home. In the home, individuals should be educated on the importance of stepping on the scale daily, at the same time of the day, and recording their weight. This is just one example of the many variables that can lead to heart failure exacerbations. Case managers play an integral role in developing strategies that effectively transition individuals with heart failure to different levels of care and/or home.

Healthcare organizations must invest in resources to ensure that individuals with heart failure, or any other high-risk group, have the necessary tools to succeed at the next level of care. Transitions of care includes doing effective medication reconciliation. Often, the idea of who owns this process has been an ongoing conversation between physicians, nurses and/or pharmacists. In the end, every effort should be made to ensure we are setting up each person we take care of for success.

As case managers, our most important role is to advocate for the resources and tools that will benefit the individuals and populations we serve. Often, I hear that someone is non-compliant with their heart failure treatment plan. The question we should ask ourselves is: Have we given the person with heart failure the tools and education to be adherent to their treatment plans? Obviously, individuals do have the right to make wrong decisions and not follow recommendations to improving or maintaining their health. In my experience, these individuals are few and far between. Many times, we have not considered the best evidence-based approaches in helping individuals understand the “why” behind the recommendations. Education is critical and should be provided by each discipline involved in a systematic and consistent way so that we are promoting the opportunity for each individual to be successful with their disease progression.

As case management leaders, we have an opportunity to champion programs and resources that engage front-line case managers, regardless of practice settings, to have meaningful discussions with high-risk individuals. The competition for budget dollars is intense in many organizations, so understanding how to construct programming proposals that include a return on investment (ROI) is essential in getting the resources necessary. As a case management profession, we have a responsibility to provide case management leaders with education on how to construct programming proposals with ROI and how to effectively have conversations with their organization’s executive leaders.

Finally, it is essential to include the individual and their caregivers in the care management plan.  As a case management leader, I often hear how the individual and/or family members were not included in a bi-directional conversation. Research continues to demonstrate that including individuals and their families in the conversation produces better adherence to the treatment and/or care management plan. Cultural beliefs and/or language barriers should not be an excuse for not including the individual and their family. Federal regulations require healthcare organizations to have access to interpreters, and it is the right thing to do to promote consumer engagement. Heart failure continues to be a disease that we can achieve better outcomes with through further engagement, tools, and resources.

Jose Alejandro, PhD, RN-BC, MBA, CCM, FACHE, FAAN

President, CMSA


Dr. Alejandro is the director of case management at UC Irvine Health, Orange County’s only Level 1 Trauma and Burn Center.

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