MiCMRC Educational WebinarManagement of Heart Failure

April 25, 2017

MiCMRC Care Management Educational Webinar:Heart Failure Management

Expert Presenter:

Karen Jackson, RN, MSNCare Manager, Integrated Health Associates

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MANAGING HEART FAILURE

Karen Jackson, RN, MSN

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Objectives

• What is Heart Failure• Why Heart Failure is a Problem• Managing Heart Failure• Engaging Patients in Self-Management• Case Study

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HEART FAILURE FACTS

• About 5.7 million adults in the United States have heart failure.

• One in 9 deaths included heart failure as contributing cause.• About half of people who develop heart failure die within 5

years of diagnosis.• Heart failure costs the nation an estimated $30.7 billion each

year. This total includes the cost of health care services, medications to treat heart failure, and missed days of work.

CDC, (2016). Heart Failure Fact Sheet. Retrieved from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm

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HEART FAILURE DEFINED

Heart failure can occur when there has beensome type of damage done to the heart thatprevents it from pumping blood adequately,such as hypertension, MI, renal failure, diabeticlarge and small vessel disease or coronary arterydisease.

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Healthy Heart vs. Heart Failure

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TYPES OF HEART FAILURE

Systolic HF typically is inability of the left side ofthe heart to pump blood adequately and isdefined primarily by Left Ventricular EjectionFraction (LVEF) of 40 percent or less.

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TYPES OF HEART FAILURE

Diastolic HF typically occurs when there isobstruction or enlargement of the right side ofthe heart does not allow blood to get into theheart adequately. Diastolic HF is most commonlyseen in patients with hypertension, COPD orpulmonary hypertension.

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Worsening Heart Failure

• Increased shortness of breath• Decreased urination• Chest pain or heaviness• Worsening edema• Increased weakness or fatigue• Confusion and agitation• Increased coughing• Weight increase4/27/2018 14

PATIENT EDUCATION

• Daily weight• Low NA diet• Fluid limit• Medications• Follow Heart Failure Action Plan

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Managing Heart Failure to avoid Hospitalization

• PCP appointments • Collaboration with PCP and Cardiologists• Homecare involvement• Cardiologist appointment• Identify barriers

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A Note about Homecare

• Importance of collaboration with homecare.

• Understanding homecare services (visit structure, monitoring services offered).

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Impacting Your Patients

Collaboration with hospital discharge planners to form an interdisciplinary partnership.

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Benefits of Patient Engagement

Patient engagement in chronic disease care is cited as being critical for improved health outcomes and reducing costs.

Simmons et al. Genome Medicine 2014, 6:16. Retrieved from http://genomedicine.com/content/6/2/16

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Patient Engagement Defined

• Patient takes an active role in his/her health.• Patient has knowledge, skills, and confidence

to manage health.• Patient performs health-promoting behaviors.

Simmons et al. Genome Medicine 2014, 6:16. Retrieved from http://genomedicine.com/content/6/2/16

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Engaging your Patient

• Understanding the patient experience • Patient concerns since discharge• Goal Setting• Steps to prevent re-hospitalization • Care Managers as their partner

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Assessing Patient Engagement

• Patient Activation Measure• Motivational Interviewing• Teach-back

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Patient Activation Measure (PAM)

Who: Patient Activation Measure • PAM reliably predicts future ER visits, hospital admissions and

readmissions, medication adherence. What: 10 Questions that provides patient specific level • PAM identifies where an individual falls within four different

levels of activation. This gives providers and health coaches insight to more effectively support each individual.

Where: Over the Phone or Face to Face Encounter When: Initial call & every 3 months • Each point increase in PAM score correlates to a 2% decrease

in hospitalization and 2% increase in medication adherence.

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Diet & Nutrition for CHF

PAM LEVEL 1:Goal: Understand how Diet

Impacts heart health.• Explain the link between diet and CHF ~

the heart does not have to work as hard when individual consumes a healthy diet and maintains a healthy weight.

• Explain what foods to eat more of ~ whole grains, fruits and vegetables, low- or non-fat dairy, skinless poultry and fish, nuts and legumes, etc.

• Explain what “nutrient density” means ~ foods that contain the most healthy nutrients and the fewest calories ~ vegetables, fruits, beans, seafood, lean meats, etc.

PAM LEVEL 4: Goal: Maintain a heart- heathy diet • Maintain ideal calorie intake over time ~ use

a diet and activity-tracking tool.• Maintain portion control over time ~ at

home and in restaurants. Use the American Heart Association as a guide.

• Try to have at least 3 meatless days, or more, each week ~ instead, choose low-fat, high-protein combined protein dishes like beans & rice, whole grain bread & peanut butter, non-fat yogurt & fresh fruit, low-fat milk & whole-grain cereal, and roasted almonds & low-fat cheese.

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Motivational Interviewing

In motivational interviewing collaboration and trust are established to support partnerships.Motivational interviewing promotes change by utilizing 4 basic skills.

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Motivational Interviewing Skills

• Open-ended questions• Affirmations• Reflective listening• Summary statements

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Principals of Motivational Interviewing

• Express Empathy• Support Self-Efficacy• Roll with Resistance• Develop Discrepancy

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Spirit of Motivational Interviewing

• Collaboration • Evocation• Autonomy

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Teach-Back

The teach back process is a systematic mannerof educating patients and assuring theyunderstand the information presented. It hasbeen researched (Schillinger; University of NorthCarolina, Iowa Health Institute) and shown toresult in improved patient outcomes.

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Teach-Back

Teach-back uses evidence based health literacyintervention that promotes patient engagement.It is a gateway to better communication, betterunderstanding, and shared decision making.

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Goal of Teach-Back

The goal of teach-back is to explain medicalinformation clearly so that patient and familiesunderstand what you have communicated tothem.Teach-back requires patient and family membersto explain in their own words what they need toknow or do. It is not just repeating what theyheard, you ask them to teach it back.

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Teach-Back Validation

Teach-back validation requires that the clinicianhas explained medical information clearly andthat patients and/or family members have aclear understanding of what you have told them.Teach-back positively correlates with improved patient adherence and outcomes.

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Is Your Patient Engaged?

• Ability to preform self care– Can they self monitor, perceive and identify

changes in function– Can they judge the meaning and severity of

changes– Can they assess options for action to manage

changes– Can they select and perform appropriate actions

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Noncompliance

If your patient is non complaint is it:-Lack of adequate and specific instructions about treatment regimens-Depression

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Palliative Care

Ensure patients know the difference between Palliative Care and Hospice Care.

• Palliative Care –Prevents and treats symptoms/side effects of disease.

• Hospice- Provides supportive care to those in their final phase of terminal illness.

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Hospice Care

• Hospice Care is about quality of life• Services offered-

– RN- assess and manage symptoms.– Home Health Aid- assists with ADL.– MSW- EOL planning, journaling life review, helping

patient sort out what’s important to them.– Spiritual Care- whatever this means to the patient.– Ancillary services.

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Case Study

77 year old female who lives in an ALF with dx.CHF, COPD, and DM. Good understanding of herDM, counts carbohydrates, fats, and proteins.Fastings are WNL and HgbA1C is less than 7.Former smoker, uses inhalers as instructed.Frequent URIs, had pneumonia and the flu thiswinter. Daily weights are completed, andmaintains FR. Difficulty with Low NA diet.

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Advance Care Planning

Get this done!

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