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Parameter #
1: Correct Categorization:
Ejection Fraction < normal – by definition this is systolic dysfunction[1];
diastolic dysfunction, the EF is normal; can be combined systolic and
diastolic. (Consider fluid overload as a separate etiology) Parameter #
2: Hospitalization Reserved for First Episode of Moderate
to Severe Heart Failure; all other cases managed on an out-patient basis Parameter #
3: Hospitalizations for Recurrent
Heart Failure. All the right things were appropriately done, but did
not succeed. Parameter # 4:
Basic Treatment of Systolic Dysfunction - One or more Level I Digoxin, Diuretic, ACE-inhibitor Level II Digoxin, B-Blocker (e.g., Carvedilol when euvolemic];
possibly an ACE-inhibitor and/or Diuretic Level III Digoxin & Lasix; Metolazone/Digoxin; Beta
Blocker as above; Lasix/HCTZ Level IV Digoxin, Even More
Aggressive Diuresis, Amiodarone ·
ACE inhibitors
/ Beta Blockers for all patients unless contraindicated or not tolerated
(e.g., cough) ·
Hydralazine and
isosorbide dinitrate in patients that can't take ACE inhibitors ·
Diuretics for
patients with volume overload (to achieve volume homeostasis; i.e.,
neither overloaded nor dehydrated) ·
Digoxin in patients
not responding adequately to above drugs or patients with atrial fibrillation
and rapid ventricular rate ·
Assess for ischemia
(stress ECHO or radionucleotide study); the need is based upon new or
changing symptoms, or ECG findings ·
Treat if present
(e.g., with Nitrates, B-Blockers, Calcium Channel Blockers; or, Cath.
and fix based upon the results) Parameter # 5: Treatment
of Diastolic Dysfunction ·
Diuretics and/or
ß-blockers and/or Nitrates ·
Avoid digoxin ·
Assess for ischemia
and treat if present ·
Nitrates, Calcium
Channel Blockers ·
Control hypertension ·
Step Therapy Parameter # 6:
Prevention of Pulmonary Embolism, or Thrombotic Stroke ·
Anticoagulation
in patients with atrial fibrillation or a previous history of systemic
or pulmonary embolism Parameter #
7: Documentation that the
Cardiologist’s Office Arranged Follow-up Care after a Change in Cardiac
Status: ·
The greatest
single quality of care issue and cost-effective preventive–maintenance
procedure after an adverse clinical outcome such as a visit to the ER
or a hospitalization or if the condition worsens is a f/u visit with
a caring practitioner within 7-10 days of discharge Parameter #
8: Monitor weight change (HMO
or DSM providing scale if necessary); report weight gain of >3-5 pounds in so many days Parameter # 9: Diet
--Sodium restriction; K+ supplementation on most diuretics Parameter # 10:
Additional measures (all) ·
Clinical assessment
of functional capacity (HMO/DSM will provide a monthly standard instrument
for the patient to fill-out; periodically, this will be supplemented
with quality of life and patient satisfaction surveys) ·
CMS and NCQA
are very interested in QOL. Consider
the following survey tools: Minnesota Living with Heart Failure Questionnaire,
Kansas City Cardiomyopathy Survey, SF-12 or 36 with specific knowledge
base or compliance indicators added.
For periodically assessing functionality, many use the 6-minute
walk test, both pre- and post. ·
Counsel patient,
family and/or caregivers; define / clarify expectations to the extent
possible ·
Chart Documentation
stressing the importance of complying with treatment ·
Chart Documentation
encouraging moderate exercise to tolerance; it is prudent to have a
pre-exercise evaluation (exercise tolerance test [VO2 max]) ·
%
with B/P <130/80 ·
%
on ACE Inhibitors (all classes), and separately % on ACE Inhibitors
(class III & IV)[2] ·
%
with LDL<100mg/dL ·
Avg. # days of
lost activity ·
Flu vaccine and
Pneumovax history or immunization Case Management Criteria (for CM Nurses)1)
Definition
of CHF: CHF is Shortness of Breath; the Presence or Absence of Edema
Should be Noted a)
A
Confidentiality Statement is a Prelude to Enrollment in this DSM (Privacy
Issue) b)
Patient
demographics c)
Contact
names d)
Relevant
phone numbers e)
Explain
this program and document same to Caretakers 2)
Determine
routine needs of the patient i)
Weights
(frequency) ii)
I&O
(Has patient been instructed to limit their fluid intake?) iii)
Special
Dietary Needs iv)
Exercise
Needs / Abilities (1)
Feet
elevation, Circulation, etc. v)
Rx (1)
Diuretics (2)
ACE Inhibitors (3)
Cardiotonics
like Digitalis (4)
CA Channel Blockers (5)
Beta Blockers (6)
Nitrates (7)
Others 3)
Determine
extraordinary needs of the patient, for example i)
O2 ii)
IV
Rx (e.g., IV Lasix, Dobutamine Therapy) iii)
Polypharmacy
(Multidrug) Therapy Coordination (>4 drugs/day) 4)
Summarize
the Patient’s History a)
Hospitalization(s) i)
CHF ii)
Other
Cardiac iii)
Other
related as in renal failure b)
ER
visit(s), if any i)
CHF ii)
Other
Cardiac iii)
Other
related as in renal failure c)
Last
medication adjustment d)
Last
switch of PCP e)
Last
cardiologist (name and visit date) f)
Marked
Positive Family History g)
Co-Morbidities
and how are they being managed i)
CAD
(treated separately in many respects) ii)
Smoking iii)
Anemia iv)
Hypertension v)
Rhythm
Disturbance vi)
Vascular
Insufficiency, PVD vii)
DM viii) Renal Failure ix)
Asthma
/ COPD x)
Endocrine
Dysfunction xi)
Pul.
Emboli xii)
Other 5)
Obtain
permission from the PCP (not just the hospital attending) to help manage
this patient with case management (e.g., outreach, outcome measurement,
monitoring) in the most cost-efficient setting a)
Determine
Frequency of monitoring or treatment visits (e.g., home care) i) Acute or “Crisis” phase ii) Longer term or “Stabilization “ phase 6)
Concurrent
Review a)
Recent
Hospitalization(s) i)
CHF ii)
Other
Cardiac iii)
Other
related as in renal failure b)
ER
visit(s), if any i)
CHF ii)
Other
Cardiac iii)
Other
related as in renal failure c)
Last
medication adjustment d)
Last
switch of PCP e)
Last
cardiologist (visit date; tests, if any and results) f) New Co-Morbidities and how are they being managed
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