Management of Acute Heart Failure from Admission to Transition
Unit 2: Discharge & Primary Care

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HD #2 18:00 Medical/Surgical Unit

Mr. Sanchez was transferred to the medical unit mid-morning. The team is preparing for his discharge in 1-2 days.
A team-based approach in HF management has been shown to:

  • Reduce hospital readmissions
  • Assist with behavior change
  • Promote therapy adherence

Who is important to include on the team at this time to support a successful transition of Mr. Sanchez’ care from the inpatient to the outpatient setting?

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  • Patient and family
  • Acute Care Provider/Hospitalist
  • Pharmacist
  • Cardiologist/Heart Failure Specialist (if available)
  • Social Worker
  • Dietician
  • Nurse (with expertise in heart failure)
  • Primary care provider

Tingley J, Dolansky MA, Walsh MN. Team-based transitions of care in heart failure. Heart Fail Clin. 2015 Jul;11(3):371-8. doi:10.1016/j.hfc.2015.03.003.



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Please click on each of the buttons below to learn what each provider is responsible for at this time.

Acute Care Provider/Hospitalist
Pharmacist
Social Worker

Dietician
Nurse
Primary Care Provider

Albert, N. M., Barnason, S., Deswal, A., Hernandez, A., Kociol, R., et al. (2015). Transitions of care in heart failure: A scientific statement from the American Heart Association. Circulation Heart Failure, 8, 384-409. doi: 10.1161/HHF. 0000000000000006


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Family Member/Friend

It is also important to involve a family member or friend designated by the patient as part of the care team.

What is the role of this person when transitioning patients to outpatient care?




     
  • Support the patient to express their needs and ask questions
  • Listen to health information and help the patient process and understand recommendations in the context of home
  • Help patient engage in care plan and support behavior changes, medication regime, and follow-up appointments

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HD #3 1100 Medical/Surgical Unit

As the inpatient provider, what are some of the methods to provide proper handoff to Mr. Sanchez’ primary care provider (PCP) about the events of his recent hospitalization?

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  • Send discharge summary via the electronic medical record (EMR) to PCP if within same health care system
  • Send written medical record (including discharge summary) to PCP (if not within the same health care system)
  • Call PCP for handoff/courtesy call
  • Provide patient with a written summary of hospitalization and discharge instructions in lay language in both Spanish and English
  • Ensure patient has an appointment for follow up with PCP prior to discharge and that this information is included in patient’s discharge summary

Clinical Pearl...

Because inpatient providers frequently change patients’ medications and treatments during HF readmissions, it is important to schedule and arrange early follow-up prior to the patient’s discharge. A follow-up visit with a practitioner should be within 7 days, with a telephone call to the patient within 48-72 hours of discharge from the hospital.

Yancy et al. 2013 ACCF/AHA guideline for the management of heart failure. doi: org/10.1161/CIR.0b013e31829e8807


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HD #3 1100 Medical/Surgical Unit

What pertinent details should be included in the communication to Mr. Sanchez’ PCP?


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  • Patient’s diagnoses on admission and discharge
  • Summary of key hospitalization events/complications, including medications, procedures, pertinent lab results, including most recent chemistry panel, renal function, and cardiac biomarkers, specifically BNP or NT-proBNP), treatments, any discussions regarding goals of care, if provider order for life sustaining treatment (POLST) completed, etc.
  • Discharge plan of care, including medications, diet, activity, follow-up plan, including systolic blood pressure goal of ≤ 130 mm Hg and dietary/fluid restrictions.
  • Teaching and observing competency with medication management and any other new care needs

Clinical Pearl...

If the discussion of goals of care with Mr. Sanchez’ indicated an interest of moving towards optimizing quality of life versus continuing curative approaches, it would be appropriate to consult palliative care prior to discharge.

    Services that the Palliative Care consultant could provide at this time include:
  • Expert symptom assessment and management
  • Psychological distress management
  • Assist the patient and families/caregiver in understanding prognosis and treatment options
  • Caregiver support
  • Discussion of and advocating for patient preferences regarding end-of-life care and when specific care is appropriate

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Follow-up Visit (1 week after discharge)

One week later, Mr. Sanchez visits his primary care provider. He arrives at the clinic accompanied by his wife. He is called back by the medical assistant (MA) and escorted to a clinic exam room. The MA asks Mr. Sanchez to have a seat on the exam table. She takes his vital signs and inquires about any complaints of pain. Mr. Sanchez denies complaints of pain, but tells the MA that he has felt tired since he has been at home.

The MA notifies the PCP that Mr. Sanchez is ready and waiting to be seen. The PCP logs into the EMR system and notes the following:

VS: T 37.0o C, HR 56 bpm, BP 101/62 mmHg, RR 16 bpm, SpO2 97% on room air (RA), weight 119.5 kg

What activities would the primary care provider conduct at this first post-discharge visit?


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  • Conduct medication reconciliation
  • Assess for problems or issues since discharge, specifically explore the patient’s complaint of fatigue further
  • Adjust plan of care as needed based on history and physical exam
  • Communicate current status and any changes in plan to Mr. Sanchez and his wife as well as any other consulting providers (e.g. cardiologist)
  • Reinforce coaching on self-management activities

Clinical Pearl...


    Weight, as well as other signs/symptoms of acute HF discussed previously, should be assessed and discussed with HF patients at every visit, especially at the 1st follow up visit after an acute exacerbation. Patients should be educated on the importance of following their weight as a sign of fluid overload. They should be given the following instructions:
  • Same scale
  • Same time of day
  • Same amount of clothes or no clothes.

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Follow Up Visit (continued)

At this post-discharge follow-up visit, it is noted during medication reconciliation that Mr. Sanchez has not been taking his Metoprolol XL 12.5mg as ordered. He stated that he didn’t pick up his prescription yet, since he already had metoprolol succinate 25 mg in his medicine cabinet, so he decided to just take that for now until he runs out of it.

Based on this information and the available data for this visit, what should the PCP do in response?


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The PCP should explore why the patient chose to use up other medication first versus getting the new prescription filled. The PCP should also reinforce with Mr. Sanchez the importance of taking medications as prescribed and needs to explain that the prior prescription was actually a larger dose than the prescription he was sent home from the hospital with on discharge. The PCP should explain that his heart rate is a little slow and that might be the cause of him feeling tired, as well as fatigue can be a side effect of the medication. The PCP should use teach back methods to ensure Mr. Sanchez understands his medication regimen, and the rationale for the lower dose.

Clinical Pearl...



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OUTPATIENT PHARMACY VISIT

Mr. Sanchez’ PCP changes his medication regimen to include metoprolol XL 12.5 mg orally daily and discontinuing/discarding the metoprolol succinate supply remaining at the patient’s home.

The PCP arranges for Mr. Sanchez and his wife to visit the outpatient clinical pharmacist in the clinic after his PCP visit as part of the multidisciplinary approach to managing heart failure.

What is the role of the outpatient clinical pharmacist in Mr. Sanchez’ care at this time?


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  • Provide patient education on medications (including purpose and adverse effects)
  • Identify potential barriers (logistical, psychological or socioeconomic) to medication adherence
  • Recognize methods to enhance medication adherence
  • Reinforce patient education on:
    • disease process
    • monitoring of signs/symptoms of worsening HF

McNeely EB. Treatment Considerations and the role of the clinical pharmacist throughout transitions of care for patients with acute heart failure. J Pharm Pract. 2016 Apr 28. pii: 0897190016645435.
Warden BA, Freels JP, Furuno JP, Mackay J. Pharmacy-managed program for providing education and discharge instructions for patients with heart failure. Am J Health Syst Pharm. 2014 Jan 15;71(2):134-9. doi: 10.2146/ajhp130103.


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Barriers to Patient Engagement

Which of the following barriers to engagement in a therapeutic regimen has been evident for Mr. Sanchez during this case study? (Check all that apply.)

  • Learning/knowledge deficit
  • Cognitive barriers
  • Financial barriers or lack of resources
  • Depression or other psychological illnesses
  • Lack of adequate social support
  • Ethnic beliefs and/or language barriers
  • Physical barriers (for example blindness or physical deficits after a stroke)
  • Access to healthcare providers




Clinical Pearl...

All of the above barriers may be present for all patients, but are especially common in HF patients.


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5 Weeks After Discharge from the Hospital

Mr. Sanchez is seen back in clinic with his primary care provider one month later. He is taking medications as ordered, and though he doesn’t like the dietary restrictions, he states that “my wife is keeping me straight.” His weight has been stable within 1.5 lbs. and he reports no increase in symptoms. He notes that he has an appointment with the cardiologist in 2 weeks. He has returned to work, and has resumed his normal exercise regimen of walking. Mr. Sanchez and his wife walk approximately 3 miles most days of the week. He is excited about an upcoming fishing trip with his son in the next month. He recognizes the importance of living a healthy lifestyle to enable him to fully participate in and enjoy such a trip, and the impact heart failure exacerbations can have on his life.


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You have now completed the case study.
Please click on the link below to provide feedback on your experience.

Heart Failure Care Evaluation


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Click below to hear 2 very different conversations between Mr. Brown and his medical provider(s) about his current situation.

Flawed Conversation

Please listen to the conversation and suggest how improve it.


Suggest 3 ways to improve the conversation.

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  • Follow patient’s wishes to have his sister present at the meeting.
  • Include other providers (nurse, social worker) in the conversation to ensure all aspects of care (mental, physical) are being addressed.
  • Don’t rush important conversations.
  • Answer the patient’s questions about his condition clearly, and in terms the patient and family can understand.
  • Ask the patient to explain what they understand about their condition at this point.

Now click on the "Improved Conversation" button to hear a revised version of the conversation

Improved Conversation

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Click below to hear 2 very different conversations between Mr. Brown and his medical provider(s) about his current situation.


Flawed Conversation

Please listen to the conversation below and suggest how improve it.



Suggest 3 ways to improve this conversation to not cause undue stress for the patient and family.



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  • Explain the different medical decisions in terms the patient can understand.
  • Reinforce that the plan can change at any moment based on what the patient desires.
  • Accept that a patient’s choices may be different than those a provider may make.

Now click on the "Improved Conversation" button to hear a revised version of the conversation

Improved Conversation

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Acute Care Provider

What are the responsibilities of the Acute Care Provider in the ED and ICU?

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  • Assess and manage heart failure in the acute care phase
  • Discuss and document advance directives
  • Consults specialty providers (pharmacist, cardiologist, etc.) as appropriate.
  • Provide timely and accurate hand-off communication to patient’s care team during patient transfers
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Cardiologist

What are the responsibilities of the Cardiologist in the ED and ICU?

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  • Assessment and management of HF
    • Recommendations and evaluation of GDMT
    • Echocardiogram reading & interpretation
    • Consults specialty providers (pharmacist, cardiologist, etc.) as appropriate.
    • Recommendations for advanced heart failure therapies for example, implantable cardioverter defibrillators (ICDs), cardiac resynchronization therapy (CRT), left ventricular assist devices (LVADs), or heart transplantation as appropriate
  • Assessment and management of other cardiovascular diseases that may contribute to or cause heart failure
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Pharmacist

What are the responsibilities of the Pharmacist in the ED and ICU?

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  • Obtain medication history
    • Determine whether patient is experiencing problems with medications
    • Adherence, side effects, cost, etc.
    • Reconcile medications - prescribed, taken, other
  • Provide treatment recommendations
  • Recommend appropriate monitoring of medications
  • Educate other team members on pharmacodynamics, appropriate doses, adverse effects, drug interactions, and monitoring of heart failure medications
  • Handoff to other units

McNeely, E. B. (2016). Treatment considerations and the role of the clinical pharmacist throughout transitions of care for patients with acute heart failure. Journal of Pharmacy Practice. doi: 10.1177/0897190016645435

Tingley, J., Dolansky, M. A., & Walsh, M. N. (2015). Team-based transitions of care in heart failure. Heart Failure Clinics, 11(3), 371-378. doi: 10.1016/j.hfc.2015.03.003.

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Acute Care Provider/Hospitalist

What is the role of the acute care provider/hospitalist while caring for patients on the medical surgical unit during the transition from inpatient to outpatient care?

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  • Manage heart failure (possibly in collaboration with cardiologist/heart failure specialist depending on available resources
    • GDMT of heart failure and overall management
    • Medication therapy
    • Diet
    • Lifestyle modification
    • Follow-up plan of care including patient instructions
  • Provide patient/caregiver education regarding disease
  • Communicate and provide timely handoff to outpatient providers to include a copy of discharge summary

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Pharmacist

What is the role of the clinical pharmacist in the care of patients with HF prior to discharge?

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  • Recommend discharge medications
  • Reconcile discharge medications
  • Identify potential barriers (logistical, psychological or socioeconomic) to medication adherence
  • Provide patient education on discharge medications verbally and in written format
  • Assist patient with patient assistance program if needed

McNeely EB. Treatment Considerations and the role of the clinical pharmacist throughout transitions of care for patients with acute heart failure. J Pharm Pract. 2016 Apr 28. pii: 0897190016645435.
Wiggins BS, Rodgers JE, DiDomenico RJ, Cook AM, Page RL 2nd. Discharge counseling for patients with heart failure or myocardial infarction: A best practices model developed by members of the American College of Clinical Pharmacy's Cardiology Practice and Research Network based on the Hospital to Home (H2H) Initiative. Pharmacotherapy. 2013 May;33(5):558-80. doi: 10.1002/phar.1231.



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Social Worker

What is the role of clinical social worker in discharge planning for patients with HF?

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  • Assess patient’s discharge needs and care goals
  • Discuss strategies to overcome barriers to meeting care goals
  • Connect patient to home health and other discharge referral agencies.
  • Assist with transportation to home and to follow-up appointment
  • Assist with any issues obtaining ordered medications
  • Assist patient with advance directives
  • Liaison between medical providers and patient/family
  • Provide emotional support and counseling for coping with illness

Rasmusson, K., Benuzillo, J., Budge, D., Horne, B., Roberts, C. et al. High risk heart failure patient multidisciplinary care pathway: Improving care and outcomes. Journal of the American College of Cardiology, 2015; 65(10), A1019.



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Dietician

What is the role of the dietician in planning for discharge of patients with heart failure?

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  • Recommend and assist patient with an individualized nutritional plan, including daily caloric needs, ideal body weight, heart healthy diet (including low sodium diet), and fluid restriction
  • Educate on nutritional needs, diet restrictions (including comorbidities), fluid restrictions, and alternative ways to take medications that may potentially interact with certain nutrients for heart failure patients
  • Include family/significant others in education about shopping, meal preparation and dietary restrictions
  • Provide adaptive strategies that respect cultural beliefs/rituals, but allow for adherence to diet and fluid regimen

Jaarsma T. Health care professionals in a heart failure team. Eur J Heart Fail. 2005 Mar 16;7(3):343-9.


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Nurse

What is the role of the nurse specializing in heart failure during transitions of care?

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  • Assess patient level of engagement, self-activation, and self-management
  • Identify barriers to adherence to HF regimen (including lifestyle behaviors and medications)
  • (Re-)Educate patient on heart failure self-management
    • Daily weights
    • Dietary and fluid restrictions
    • Medications
    • Understanding of “red flags” indicating change in health condition
    • Discharge instructions and follow up appointments
  • Facilitate communication
    • Between patient and providers
    • Between patient and caregivers
    • Provide transitional post-discharge follow-up often using telemonitoring (remote monitoring home program which aids in monitoring for early signs of HF from a distance).
  • Engage in quality improvement activities around HF core measures

Self-management is when the patient participates in the care of his/her heart failure and involves healthy lifestyle modification, medication and other heart failure therapy adherence, understanding and recognizing signs and symptoms of worsening heart failure.

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Primary Care Provider (PCP)

What is the role of the PCP during the transition of patients to outpatient care?

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  • Communicate with inpatient provider regarding hospital events and follow-up care
  • Follow-up visit for patient to be seen within 7 days of hospital discharge

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An electrocardiogram (ECG)

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CXR:

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Acute Care Provider

Manages care for an acute illness or injury, typically for a short duration while in a hospital setting. Depending on the setting, this may be a Physician, a Nurse Practitioner, or a Physician Assistant. Additionally, the acute care provider discusses and negotiates the plan of care with the patient and family.

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Blood Tests

Blood Alcohol Level: 0
INR: 1.0 (normal)
PTT: 35 seconds

CBC:
Hgb 9.9 g/dL
Hct 38%
Platelets 152,000/mm3
WBC 12,000 cells/mcL
Neutrophils 70% - Hi
Lymphocytes 23%
Monocytes 6%
Eosinophils 1%
Basophils 0.2%

BMP:
BUN 27 mg/dL
CO2 22 mmol/L
Creatinine 0.95 mg/dL
BUN/Creatinine Ratio: 28 - Hi
Glucose 310 mg/dL - Hi
Sodium 112 mEq/L - Lo
Chloride 85 mEq/L
Potassium 4.3 mmol/L
GFR calculated: 57.7 mL/min/1.73 m2 - Lo
Troponin: 0.01 ng/mL negative
CK: 50 U/L


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Urinalysis

U/A- wnl, except for + protein
Urine Toxicology Screen-negative

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Radiology




Multiple left-sided rib fractures. Most of these appear to be chronic and healed; however, there are acute-subacute appearing fractures of the anterolateral aspect of the left 4th and 5th ribs. Ununited chronic fracture of the lateral aspect of the left 6th rib.



Spine CT: No fractures.





Head CT: 3mm right acute on chronic holohemispheric subdural hematoma without shift. No noted skull fractures.

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Pharmacy Consult

The rationale for this consult is to obtain pain medication recommendations.

What should be ordered for this patient?

  • Fentanyl 25 mcg IV
  • Morphine sulfate 1mg IV
  • Meperidine 25 mg IM
  • Midazolam 0.5 mg IV

Green answer is the best choice.





Clinical Pearl...

Listen to the pharmacist’s rationale for drug choice




Photo courtesy of UW Medicine.

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Social Worker Consult

The rationale for obtaining this consult is the presence of multiple rib fractures; need for assessment of possible elder abuse and locating legal next of kin (LNOK).


Social worker reports that she has attempted to contact patient’s daughter, but has not been able to reach her. Social worker will continue to reach out to daughter and locate other family members. Once family has been reached, social worker will conduct safety assessment for Mrs. Castillo, including assessing for possible elder abuse or neglect due to rib fractures.

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Neurosurgery Consult

The rationale for obtaining this consult is for surgical evaluation of the patient’s subdural hematoma.

Neurosurgery finds that the SDH is non-operable and recommends the transfusion of a 6-pack of platelets.


Clinical Pearl...

Aspirin therapy, such as Mrs. Castillo was receiving, disrupts platelet function by inhibiting COX-1 for the life of the platelet (~7-10 days). Presently, platelet transfusion for patients receiving antiplatelet agents, such as aspirin, is controversial and requires further study. A summary of work in this area is provided in the link below.