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Focus On: Ongoing Patient Surveillance for Optimal Heart Failure Management Heart failure (HF) is a chronic condition characterized by recurrent periods of clinical decompensation and repeated hospitalizations. Management of HF requires careful adherence to a complex medication and self-care regimen. However, because patients see their prescribing physicians episodically, there is little opportunity to provide the ongoing teaching and surveillance that they require for optimal management. "Numerous studies demonstrate that a multidisciplinary approach including cardiologists, nurse-led education, follow-up and telephone or internet monitoring are essential components of a comprehensive, successful management program," says Alfred Bove, Chief of Cardiology at the Temple University School of Medicine and Temple University Hospital. "Although these programs have proven to reduce patient hospital readmission rates, they are costly and often beyond the scope of the community cardiologist or primary care physician." For this reason, Dr. Bove has implemented a comprehensive heart failure program administered by two specially trained RNs. These heart failure nurses use internet tools or automated telephone programs to gather patient data on changes in weight, vital signs or symptoms of disease progression. "The program is based on the premise that many HF patients experience health status deterioration, an increase in weight and/or other subtle symptoms days or weeks before requiring hospitalization," says Dr. Bove. "The monitoring system alerts us to these early signs and symptoms of decompensation, and allows us to intervene before the patient becomes severely ill. Ongoing communication also enables the nurses to address patient concerns and encourage treatment compliance at home." The Temple Heart Failure program invites physicians to enroll heart failure patients in this exciting plan of care early in their disease process for optimal patient outcomes. As an academic medical center, Temple collaborates with community physicians by providing the information systems and professional staff needed to administer the program. Physicians receive regular faxed reports detailing changes in the patient's condition. This partnership helps referring physicians, who ultimately provide care management, shoulder the continuing care burden of these resource-intensive patients. An additional feature of the program is that ongoing education and close monitoring encourages the patient's active participation in self-care. For more information about the heart failure surveillance program, or to enroll your patient, contact. < Back
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