USA Heart Failure Center



MISSION

Provide patient and family centered care using Guideline-Directed Medical Therapy (GDMT) to decrease morbidity and mortality, and improve quality of life


INITIATIVES

Therapy of heart failure according to the latest ACC/AHA/HFSA clinical practice guidelines
Reliable access to multidisciplinary care providers
Engaging patients to participate in their own medical care and promoting self-care
Adherence education and monitoring to GDMT in the inpatient and outpatient settings
Transition of care to assure continuity of care between inpatient and outpatient settings
  Centered care around patients and families
  Hospital admission, readmission and length of stay mitigation measures
  Fostering an atmosphere of care and belonging

 

MAJOR CAUSES FOR READMISSIONS

Reassessment failure of patient care needs & desires: DNR, palliative care
Education and counseling failure: for patient and family or caregiver
Absent communication/care coordination: among health care providers
Discharge planning failure: no adequate follow-up or transition of care
Medical therapy failure: suboptimal use of or adherence to GDMT
Inadequate adherence to diet, activity, and symptom monitoring measures
Thorough assessment of psychosocial, environmental & financial issues lacking

 

USA Cardiology Heart Failure (HF)

Program Through Patient Care Continuum

 

HF TEAM

A multidisciplinary team (including case managers, pharmacist, social service, dietary, nurse manager, physician, nurse practitioners and HF RN etc.), promoting GDMT with comprehensive patient centered care across the continuum, from inpatient through transition into outpatient.

 

OBJECTIVES

Identify HF admissions
Monitor core measure adherence
Promote comprehensive patient education
Reconcile patient medications
Optimize GDMT heart failure specific therapies
Verify tolerance and adherence to medications
Encourage compliance with diet and exercise
  Help mitigate financial or any other obstacles to care
  Follow-up appointment early as outpatient to maintain continuum of care

 


OUR TEAM

 

RECOGNITION (Click on the links below)

The USA Cardiology HF Team is the recipient of:

The 2016 American Heart Association Get With The Guidelines (GWTG) Heart Failure Gold Plus Quality Achievement Award.

Recognition for quality healthcare achievement in the 2016 U.S. News & World Report congratulatory ad. [Click here for full list]

PATIENT RESOURCES (Click on the link below)

Heart Failure Society of America

American Heart Association

PHYSICIAN RESOURCES (Click on the link below)

INPATIENT HEART FAILURE NURSE PRACTIONER (HFNP) ROLE RECOMMENDATIONS

USA HEART FAILURE TEAM TRANSITIONS OF CARE RECOMMENDATIONS

PUBLICATIONS (Click on the link below)

Success in Failure: Reduction in 30-Day Readmissions in Primary and Secondary Heart Failure
Sushee Gadde, Catharine Aune, Bassam Omar, Barbara Burckhartt

Circulation: Cardiovascular Quality and Outcomes. 2017;10:A106


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