CHF CASE MANGER ROLE

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CHF CASE MANGER ROLE
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CHF Case Manager Role

• To ensure compliance with Quality Core Measures
  for CHF and MI patients as required by CMS and
  TJC
• CHF
• Discharge Instructions
• LVF Assessment
• ACEI or ARB for LVSD
• Smoking Cessation Counseling
• MI
• ASA and a Beta-Blocker w/in 24 Hrs of Admission
• LVF Assessment
• ACEI or ARB for LVSD
• ASA and Beta-Blocker Prescribed at Discharge
• Smoking Cessation Counseling

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Education of Patients

• Heart Failure and MI patients are given
  educational material on
• Smoking Cessation
• Signs and Symptoms of Disease Process
• Dietary and Fluid Restrictions
• Medications
• Activity
• Self Monitoring
• Daily Weights
• Oxygen Therapy
• Lifestyle Changes
• Follow up Care

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Education of Patients cont..

• The patients are assessed for needs and these are
  communicated with the social worker, dietary and
  other disciplines during daily team meetings.
• Families are educated and involved in the
  patients care.
• Other individuals/agencies involved in the
  patients care are also contacted

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Follow Up Phone Calls

• First Phone Call
• Made to patient w/in 24 48 hours after
  discharge.
• Discussion includes
• Follow-up on home services
• Self-monitoring and self care
• Asked if follow-up physician appointments were
  made
• Additional Calls
• Made at 2 weeks, 4 weeks and 6 weeks
• Discussion Includes
• Patient Self Evaluation of the Program
• Monitored for Compliance regarding Discharge
  Instructions
• Provided additional educational material verbally
  and via phone

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Tracking

• A Spreadsheet was Developed that includes
• Admission and Discharge Date
• Admitting Physician
• Stage of Disease
• Interventions Utilized
• Discharge Disposition
• Discharge Providers
• Use of Home Tele-Monitoring
• Sequence of the Follow up Calls
• Additional Data as Needed
• This allows the hospital to drill down for trends
  and determine what characteristics predispose
  patients to be readmitted to the hospital along
  with evaluation of the effectiveness of
  implemented interventions.

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Interventions

• PHR
• Red Flags
• CHF Zone Management Tool
• Teach back
• Post Acute Care Services and Home Tele-Monitoring
• Nocturnal Pulse ox
• CHF Disease specific Educational Materials
• Weight Log
• Follow up Phone Calls

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Up and Coming

• CHF Videos
• The Education Department is in the process of
  making available 3 videos which will be able
  to viewed on the televisions in the patient
  rooms.
• Discharge Packets
• The Nursing Department is currently working on a
  packet to be given to the patients at the time of
  discharge.
• Continued Education to Physicians on the PHR.
• Tele-Monitor Educational Session