Why was a program as specific as an outpatient congestive heart failure program started vs. a cardiac independence or rehabilitation program?

The hospital had a successful cardiac independence program in place when the idea for a CHF program was conceived. In 1998, disease management programs were new and proving successful in improving outcomes for CHF patients. Based on hospital data, the volume of CHF admissions warranted a designated nurse to manage this patient population.

Our CHF and cardiac independence programs are located within the heath center department, which allows for collaboration and continuity of care in both the hospital and outpatient setting. The CHF program is offered free to anyone in the community.

What types of patients do you typically see?

We have a variety of patient types because we provide service to both inpatients and outpatients. This program accepts all patients with a diagnosis of congestive heart failure and cardiomyopathy.

While other programs that offer health management require that patients meet certain criteria, we do not. We have patients as young as 33 with postpartum cardiomyopathy, and as old as a 90-year-old nurse who wants to know everything she can about her disease.

What I have found, unfortunately, is that there is no typical heart failure patient.

What would this program entail for the average patient?

Each patient is provided the opportunity to attend an individual educational session with me. These sessions are tailored to individual patients and their needs. The average session is two hours; some last up to three hours. If patients have difficulty with the information, they may return several times, but most have the one class. Every patient is encouraged to attend a one-hour individual class with our dietitian as well as a four-week stress management class if warranted. Sometimes, it is their spouse who needs the stress class!

After the initial class, patients are followed over the telephone if they agree. If a patient is having a problem, I will contact the physician for any necessary intervention.

Sometimes, we help get a home care referral, a hospice consultation, a medication adjustment or provide information on community resources. Patients who are discharged from the hospital and agree to telemanagement service are contacted within 48 to 72 hours, and are called weekly until stable. After that, they may be called one to two times a month depending on their needs.

We encourage family and friends' involvement, and are available to them as well. There is a lot of fear with this diagnosis, and we try to offer hope by positive support and education. Getting the patient and family back in control is the main goal. I also offer a monthly support group, which is attended by patients with every type of heart disease, including heart failure.

Patient education includes understanding your diagnosis; teaching and reinforcing self-management skills; medication adherence; diet, exercise and stress management; smoking cessation; symptom identification and an emergency plan if the patient runs into trouble.

Patient management includes a scheduled routine contact with the nurse via telephone, a supportive environment designed to enhance self-management and providing the physician with patient progress notes and discussion of modification of the treatment plan, if warranted.

What has been the response to this type of program?

Our patients and their families have been tremendously grateful for the education and support that they receive from this program. The program provides a venue for them to express their fears, frustrations and any depression that surrounds this chronic condition. It is truly a luxury for all to be able to spend this amount of time with a patient.

Initially, MDs were unsure of the purpose of the CHF program. Many were reluctant to refer their patients, either because we offered "only education," therefore having no real value in their eyes, or they felt we were potentially "practicing medicine," and overstepping our scope of practice. They are becoming more accepting.

Hospital nurses are supportive of our programs, as we assist with the inpatient education and serve as an additional resource. Disease management programs are still relatively a new concept, so there is always the question, "What exactly do you do?"

What advice do you have for other nurses who may be starting a program such as this?

Network and learn from your peers. See what works with the other successful programs your hospital may have. Be resourceful, resilient, assertive, observant and, most important of all, patient!

It takes time to build a program, to be accepted and to eventually be part of the treatment plan.