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What is a Heart Failure Disease Management Program?

Disease Management, or patient continuous care management, is a healthcare delivery model where each patient's unique medical needs and goals of care are coordinated and communicated for the best possible outcomes. The principles of a heart failure disease management program are as follows:

Traditional Care Model	Disease Management Model
Guidelines of Care Various guidelines of care are available and followed but with no enforced mechanism to ensure or measure adherence.	Measured Adherence to Guidelines of Care Ensures your healthcare providers follow the American Heart Association/American College of Cardiology and Heart Failure Society of America guidelines of care on a continuous basis and evaluates for adherence to these guidelines.
Communication Patient receives care from a provider or team who may or may not provide a communication to patient's other various providers. Patient may be asked to provide information between various providers.	Continuous Communication Effective and ongoing communication between the provider/team managing your heart failure condition and all other providers involved in your care. Communication is continuous.
Education Patients receive teaching but no process in place to evaluate the effectiveness of teaching.	Effective Education Patient/patient's family empowered with heart failure self-management education including information about what caused HF, medications, daily weights, diet, activity, lifestyle, and symptoms to monitor. Patients are evaluated for effectiveness of teaching with alteration in teaching method until goals of care are met.

Providing each patient the best standard of care acknowledges that each patient is unique, as are his or her care issues, and must be evaluated within a system that supports individualized care. It is important that you, the patient, be evaluated for your unique combination of medical issues including any co-existing medical conditions you may have such as diabetes, arthritis, kidney dysfunction, gout, sleep disorders, depression, etc. A HF care management program works with you to develop treatment goals and continuously evaluates the response to treatment so that the plan is altered and new therapies are tried then reevaluated. The continuous care management approach to heart failure management emphasizes that only through effective coordination of care, good communication between various healthcare providers, and by teaching patients how to manage this condition in between office visits, will the best HF patient outcomes be achieved.

Empowering you, the patient, with self-care education is key to successful management of your condition. Getting the information you need sometimes requires the help of various members of the multi-disciplinary heart failure team including your physician, nurse, exercise specialist, dietitian, social worker and others. Again, this team will develop a treatment plan tailored to your individual needs and follow-up with you to determine how well the plan worked. Modifying the plan to meet your needs is important for achieving effective long-term outcomes.

Heart Failure patients may have difficulty following the recommended treatment plan because of medication side effects and costs, difficulties understanding treatment instructions, and many more reasons. Dealing with these barriers to care is crucial to successfully managing your heart failure condition and preventing complications. A heart failure disease management program (or care management program) helps patients fully understand the purpose and value of their treatments and work with you to overcome barriers to treatment. The ultimate goal of a heart failure care management program is to give you the highest quality of care available and to keep you, the patient, empowered to provide yourself high quality self-management care.

Review the following checklist to determine your knowledge of heart failure self-management:

Heart Failure Self-Management Check List

1. I understand what heart failure means
2. I understand the cause of my heart failure
3. I have all of the medications prescribed for me and understand how to take them
4. I understand the purpose of each medication I take and side effects to watch out for
5. I know which over-the-counter medications to avoid
6. I keep a list of my current medications to share with all my doctors
7. I have a scale to weigh myself at home
8. I understand to weigh myself daily and to call my doctor if I experience a weight gain of 2-3 pounds over 1-2 days or 5 pounds in a week
9. I can identify signs and symptoms of worsening heart failure and know what to do if symptoms worsen
10. I understand how to eat a low salt diet (less than 2 grams in a day)
11. I understand what level of activity or exercise I may engage in
12. I know the resources to help me quit smoking if I smoke
13. I know the exact date and time of my next follow-up appointment
14. I feel confident in my ability to care for myself at home
15. I keep my healthcare provider contact name and phone number easily accessible in case I have problems