Disease Management Program:

Congestive Heart Failure: CHF

The VNA of LI's Disease Management Program for CHF:

• Enables case managers and discharge planners to safely discharge home the client with a diagnosis of CHF.
• Provides physicians with "up-to-the-minute" clinical reports.
• Allows the client to maintain a stable cardiac status, thereby improving the quality of life

Program Goals:

• Educate the client and caregiver about CHF
• Empower the client to manage his/her CHF
• Prevent hospitalization and unnecessary visits to healthcare professionals.
• Collect information to track improvement

Program Specifics:

• Identification of CHF as the Primary Diagnosis at Intake.
• Client's File is flagged for admission onto the Cardiac Program
• Registered Nurse admits the client into our home care service following the program guidelines.
• Physician recieves a letter introducing the Cardiac Program.
• With the physician's approval, we are able to provide nutritional guidance and physical therapy.
• Daily contact with the client for the first 10 days:
• Contact is a combination of nursing visits and phone calls.
• The client is encouraged to do daily self-assessments using the "Congestive Heart Failure Zones for Management Form".
• The nurse will monitor the client's weight and medication regime daily.
• Communication is maintained with the physician at regular intervals.