Improving Outcomes: Care Coordination for Congestive Heart Failure

This essay explores the development of a care coordination program aimed at reducing hospital readmission rates for patients with congestive heart failure (CHF). The program utilizes a transition care model, focusing on screening and referrals, to ensure coordinated care as patients transition between different levels of care. Key components include treating underlying causes like CHF, hypertension, and diabetes, managing symptoms, and improving self-care methods such as medication adherence. The program emphasizes quality of care through reduced 30-day mortality and readmissions, cost reduction through assessment and clinical interventions, and ultimately, reduced morbidity and mortality. Essential steps involve identifying at-risk older adults, telephone follow-ups, patient education, weight monitoring, dietary advice, exercise recommendations, medication reviews, and social-psychological support. Patients requiring specialized treatment are referred to multi-disciplinary heart failure teams, particularly those whose conditions are unmanageable at home.

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Nursing assignment
10/24/2018

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Congestive heart failure is one of the major issues, which creates a burden on the
health care system. It refers to the chronic progressive condition that affects an individual’s
pumping of heart muscles.. Thus, developing a care coordination program will focus on
reducing the hospital readmission rates of the patients with the congestive heart failure (Scott
and Winters, 2015).
The care coordination program is developed by using a transition care model, and the
screening and referrals. Transitional care model or interventions are based on evidences, and
they are designed to ensure coordination and care of their patients when they are transferred
to levels of care. The first step includes treating the patients with the underlying causes (CHF,
HTN, and Diabetes). Then managing and controlling the symptoms of the congestive heart
failure of the patient, examining the halt or slow progression of disease. Achieving the
satisfactory improvement of the quality measures includes 30-day mortality and decreased
30-day readmissions for CHF (Vedel and Khanassov, 2015).
Ensuring the quality of care provided to the patients, through improved self-care
methods, such as adherence to medication, and compliance with the plan of treatment of the
disease. The plan should be focused towards decreasing the cost of care provided to the
patients, through assessment, engagement interventions, clinical methods, and referrals. Then
the last step is to reduce the morbidity and mortality. The plan or program to prevent the
increasing rate of heart failure also includes essential steps of Screening and referrals. It
includes identifying and targeting the specific population of a group of people, older adults in
such cases who are at risk for these poor outcomes (Hall et al., 2018).
The transition care program for congestive heart failure patients include, eight aspects
or components to disease management after hospital discharge, and reduce readmission rates.
Telephone follow-up, which states that the patients are contacted through telephone call to
know about their health after treatment. It then follows with providing them education about
their health management, which includes further the aspects of self-management. Weight
monitoring is the next component of the aspects of transition care program to reduce the
readmission rates in the hospital. Sodium restrictions, advices for healthy diet, and following
recommended exercises, medication review, and the social, psychological support are the
eight components that should be considered. These components and the care must be
provided to the patients considering the fact that the principles of screening and referral must
be considered important. Patients must be screened out those who require special treatments,

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other than what is available to them. Referring them to the multi-disciplinary heart failure
team, requires initial diagnosis of heart failure, management of heart failure, especially which
does not respond to the given treatment. Including the heart failure, that is not manageable
effectively within the home-settings (Coghlan et al., 2014).

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References
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Scott, M.C. and Winters, M.E. (2015). Congestive heart failure. Emergency Medicine
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Vedel, I. and Khanassov, V. (2015). Transitional care for patients with congestive heart
failure: a systematic review and meta-analysis. The Annals of Family Medicine, 13(6),
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Coghlan, J. G., Denton, C. P., Grünig, E., Bonderman, D., Distler, O., Khanna, D. & Chadha-
Boreham, H. (2014). Evidence-based detection of pulmonary arterial hypertension in
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