Heart Failure

Patients with a primary diagnosis of heart failure (HF) account for 5.5% of patients seen by home health agencies, and these patients are at high risk of hospital readmissions. Home-based care organizations are positioned to increase quality of care and drive smarter spending by maximizing interventions that help people with HF remain safely and comfortably at home.  

Recommended Resource: Agency for Healthcare Quality And Research - Interventions to Prevent Readmissions for People with Heart Failure   (October, 2015)

This Blueprint module was developed in collaboration with the Visiting Nurse Association of New England.
ElevatingHome Best Practices
  • All patients with a diagnosis of Heart Failure should be assessed for risk of hospitalization.
  • Both non-pharmacological and pharmacological interventions for heart failure should be addressed in a systematic approach.
  • Utilize an evidence-based Heart Failure Disease Management program including teaching tools, to assure consistency in care and patient teaching.
  • Focus should be on helping patients to understand and retain information while developing self-care competencies.
Table 1: Critical Home-Based Care Interventions for Heart Failure Patients
Care Initiation
  • Obtain the following information as part of the intake process:
    1. H&P and/or hospital discharge summary
    2. NYHA and/or ACCF Classification and ejection fraction.
    3. Risk indicators for re-hospitalization & patient safety using a standardized risk assessment.
    4. Discharge/current medication list
    5. Ordered treatments
    6. Any lab tests to be done
    7. Teach-back readiness and any teaching tools used by referral source
    8. Staff concerns re discharge and safety
    9. Extent of family involvement; identified caregiver; patient representative.
  • Call/speak to patient on day of dc from a facility to ask about:
    1. Who is helping you at home?
    2. Has your breathing changed since you got home or have you had any chest pain?
    3. Were all of your prescribed medications obtained?  Any questions about them?
    4. Do you feel safe &/or do you need a visit today/this evening?
    5. Do you know who to call if your symptoms change?
  • Provide agency name and contact information and assurance of 24 hour response to calls.
  • Plan SN, Rehab and HHA schedule  – Visit frequencies weeks 1-4
  1. 3 RN visits the first week (frontloading) then 1-3 times per week (the 2nd SN visit may be done day 2 to assure knowledge by patient/caregiver)
  2. At least 1 in home visit in the first week from each of the ordered therapies then 1-2 times per week for rehab and HHA if ordered.
  3. In addition phone contact should be made on days in between visits.
  4. Admission should be within 24 hours of facility discharge when possible.
  • Implement Tele-health by 2nd visit and or telephonic communications between visits.
  • Assure physician follow-up/appointment is made within 7-10 days of discharge, and that patient has a means of getting to the appointment.
  • A comprehensive nursing assessment should be completed which includes:
  1. OASIS & total physical assessment with emphasis on cardiovascular assessment with focus on – vital signs, weight, dyspnea, lung sounds, fatigue, appetite, edema (peripheral and abdominal), chest pain, SPO2, sleep disturbances, dry cough, activity tolerance, dehydration (orthostatic hypotension).
  2. Pain status (chest/abdominal)
  3. Nutritional assessment that includes a 24-hour recall/NA restrictions/appetite.
  4. Refer to a dietician for patients who are supposed to be following 2 or more diets.
  5. Mental status
  6. Depression and anxiety screening.
  7. Refer to MSW if more extensive psychosocial evaluation is needed
  8. Activity tolerance with referral to physical therapy and/or occupational therapy
  9. Falls risk
  10. Learning ability/readiness using a tool such as the Confidence Ruler
  11. Barriers to adherence utilizing a standardized assessment tool.
  12. O2 safety and usage if applicable.
  13. Medication reconciliation using Verify, Clarify, Reconcile methodology.
  14. Patient ability to teach-back signs and symptoms of worsening heart failure and patient possession of a hard copy list of signs, symptoms and actions to take.
Ongoing Care
  • Plan visit frequency of SN and/or Rehab: 1-2 times per week. Telehealth or Telephonic calls program remains in place
  • Assess with every visit:
    1. Vital signs
    2. Cardiovascular assessment with focus on signs and symptoms of fluid overload and signs of dehydration.
    3. Request to see weight log and assess patient ability to log daily weights
    4. Pain status
    5. Nutritional assessment as above
    6. Mental status/anxiety/depression
    7. Sleep Patterns/# pillows used
    8. Cough
    9. Activity Tolerance
    10. Any falls since last visit
    11. Any changes in medication orders or usage
    12. Patient knowledge of medications to avoid that exacerbate heart failure
    13. Patient ability to manage significant co-morbid conditions (diabetes, COPD, depression)
    14. Continue to assess learning ability/readiness for change and barriers to adherence using a standardized assessment tool
    15. Educate and monitor O2 saturation, safety and usage.
    16. Offer advanced care planning & palliative care conversation if patient appropriate
Care Transition / Discharge Planning
  1. Follow-up PCP visit should be scheduled prior to discharge
  2. Any continuing lab services should be arranged
  3. Refer to private pay services and other community resources as needed
  4. Refer to Palliative care/Hospice services when indicated. Consider initiating palliative care or hospice visit during the home health episode
  5. Reconcile current medication list and hand off to next provider.
  6. Assure plan in place for medication procurement and management.
  7. See Blueprint module Prevent Readmissions /Maintain Discharge to Community
Medication therapy
Medication adherence is a problem for many patients with heart failure. Care Planning around this area should include:
  1. A thorough medication reconciliation during the SOC and ROC visit.
  2. Referral to MSW if cost or ability to obtain medications is a problem. Identify distant family members who may be involved/willing to cover costs.
  3. Assess understanding of all medication actions and side effects, and on subsequent visits adherence to medication schedule.
  4. Assist patient to develop self-care behaviors (using teach-back techniques etc.) including decisions and plans to incorporate medication taking into daily activities, obtaining initial and refill prescriptions, and managing a change of routine brought about by appointments, travel and other illnesses.
  5. Refer to OT or Speech therapy for cognitive skills if necessary to help with medication adherence.
  6. Assess for need to obtain devices such as pill boxes to help with medication adherence.
Self-management symptom monitoring
Research has demonstrated that patients delay for days before seeking care for symptoms of HF.  This delay may be due to a failure to routinely monitor symptoms or an inability to recognize and interpret symptoms when they occur.Care Planning around this area should include:
  1. Assess HF symptoms on each visit – vital signs, weight, dyspnea, fatigue, appetite, edema, chest pain, SPO2, sleep disturbances, dry cough, activity tolerance, dehydration (orthostatic hypotension).   
  2. Educate patients/caregivers both verbally and in writing using standardized tools, to improve abilities to recognize, interpret and act on early symptoms. Use teach-back to assess learning.
  3. Utilize Stoplight or Zone tools to help patients interpret and act on symptom changes.
  4. Use Remote Patient Monitoring / telemedicine as indicated as a tool for daily, repeated, serial assessments of specific symptoms to reinforce education and support patient/caregivers during this process.
  5. Teach patient/caregiver energy conservation techniques.
  6. If oxygen is ordered educate re use and safety.
  7. Help patient/caregiver to identify 1-2 achievable goals to help build confidence in self-managing own chronic illness symptoms.
Other Teaching
Dietary Adherence (sodium intake) Guidelines on the recommended intake of sodium are inconsistent as is the terminology. ACCF/AHA Guidelines for Stages A & B HF recommend 1,500 mg/day. ACCF/AHA Guidelines for Stages C & D HF  state “Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms.” It is noted that sodium intake is high in the general population, so some decrease in intake is appropriate. Care planning around this area should include:
  1. Obtain patient specific sodium restriction orders from the physician if applicable.
  2. Use evidence based sodium teaching tools such as Tips to Cut Sodium and overall lifestyle guides such as the AHA's Living with Heart Failure to encourage patients to adhere to prescribed restriction (if any).
  3. Make referrals to nutritionist/dietician if needed.
  4. Use food from patient’s cupboards to teach patient how to read labels. Evaluate ability to read sodium content by having patient sort high and low sodium foods.
  5. Educate aides who are assisting with meal preparation on low and high sodium foods.
  6. Consider administering the Newest Vital Sign Tool to determine risk of low health literacy.
Fluid Restriction: Guidelines recommend a fluid restriction <2 liters/day especially for patients with severe hyponatremia or persistent or recurrent fluid retention despite sodium restriction and use of diuretics. Research has demonstrated that routine fluid restriction in patients with mild to moderate symptoms does not confer clinical benefit. Care planning around this area should include:
  1. Obtain patient specific fluid restriction orders from the physician for appropriate patients.
  2. Use evidence based teaching tools to encourage patients/caregivers to adhere to specific restrictions if ordered.
  3. For those patients who are Stage D where referral to Palliative Care or Hospice may be appropriate, fluid restriction is not usually helpful. Patient comfort is the goal
Alcohol restriction and caffeine consumption: Advice to restrict alcohol in HF is traditional despite the fact that few data are available to guide the recommendation. Current guidelines recommend limiting intake of alcohol to no more than 1 to 2 glasses (6 to 8 oz per glass) of wine per day, or no more than 2 glasses for men and 1 for women per day. Persons with alcoholic cardiomyopathy should not drink any alcohol. Moderate coffee consumption (1 to 2 cups per day) does not appear to be harmful to anyone with heart disease.Care planning around this area should include:
  1. Ask about daily alcohol consumption when completing OASIS-C Risk Factor assessment
  2. Use consumption recommendations to provide more insight and dialogue with the patient about behavior changes.
Weight loss: Dieting may be potentially harmful in patients with HF (Riegel, 2009). Obese persons with HF have a lower mortality and hospitalization rates than patients with normal body mass index. Conversely, weight loss may reflect cachexia, the clinically important and terminal phase of body wasting found as a complication of several chronic illnesses including HF. Although evidence is not conclusive, the consensus is that if BMI is >40 kg/m2, weight loss should be encouraged to bring the BMI down to <40 kg/m2. If BMI is  <30 kg/m2 weight loss should not be encouraged. No recommendations are made for persons with a BMI between 30-40 kg/m2. Care planning around this area should include:
  1. Teach patients and staff to monitor for loss of appetite, unexpected weight loss and muscle wasting.
  2. Request dietician referral as needed.
  3. Obtain and record patient’s BMI on admission, and determine dietary advice based on BMI.
  4. Use the MyPlate Method for teaching appropriate dietary intake.
  5. Because weight loss is a powerful independent variable that predicts mortality discussion of advanced care planning and/or hospice referral should be initiated with patients who are cachectic.
  6. Teach patients to limit saturated fat, transfats and simple carbohydrates in order to maintain a healthy weight and a normal lipid profile.
Physical Activity: Routine exercise is a potent way to improve oxygen delivery and decrease inflammation within the arterial wall. It increases peak O2 uptake in HF and increases coronary flow reserve. Exercise is recommended in patients with current or prior symptoms of HF and reduced LV ejection fraction. In spite of the evidence few persons with HF report engaging in exercise. No universal prescription exists, however, guidelines suggested sustained aerobic activity for 20-30 minutes, 3-5 times a week should be a goal. Care planning around this area should include:
  1. Discuss physical activity program and goals with physician and patient.
  2. Refer to PT to establish exercise regimen to improve strength, duration and safety for ADL’s/IADLs
  3. Refer to OT for energy conservation techniques and adaptive equipment needs.
  4. Utilize modified BORG scale for perceived exertion.  AHA recommendation for patients with heart disease is to use a Borg score and maintain activity level between 13-15 on the scale.
  5. Teach simple exercises for limited mobility patients.
  6. Consider referral to an outpatient cardiac rehabilitation program post home health discharge
Smoking Cessation: Tobacco use is strongly associated with risk for increased incidence and recurrence of HF. Nicotine replacement therapy and antidepressants are recommended to help HF patients to quit smoking.Smoking cessation should be a very high priority for HF management. Care planning around this area should include:
  1. Address smoking at SOC and ROC when competing OASIS-C M1036 and throughout the episode
  2. Address smoking cessation using motivational interviewing techniques and communicate with physician on patient’s readiness to quite smoking
  3. Refer to Food and Drug Administration, NIH and CDC resources to educate patients and support quitting
  4. Determine which of the many FREE programs clinicians can use with patients.To be effective, ongoing coaching support is needed.
Preventive behaviors (infection prevention): Routine hand washing, dental health, and maintenance of scheduled immunizations may limit inflammation and infection, which have the potential to cause tissue ischemia in persons with HF. Care planning around this area should include:
  1. Work with patients to motivate them to actively participate in self-care and to be able to associate dental health, prevention of flu and pneumonia or symptom monitoring with prevention of hospitalization or other untoward HF outcomes.
  2. Document flu and pneumonia vaccine status on OASIS.
Nonprescription Medications: Patients are often unaware of the possible interactions with HF therapies and seldom inform their physicians they are using agents such as herbal remedies, alternative medicines and other over-the-counter drugs. Care planning around this area should include:
  1. Routinely ask patients about use of alternative and complementary therapies.
  2. Teach patients to maintain a written record of all medications,ncluding over the counter and herbal supplements.
  3. NSAIDS such as ibuprofen, indomethacin and naproxen are not recommended in patients with chronic HF. The risk of renal failure and fluid retention is markedly increased in the setting of reduced renal function or ACE-inhibitor therapy.
Important Co-morbidities: Many patients with heart failure have more than one co-morbidity. ACCF/AHA Heart Failure Guidelines (2013) list the top ten most common among Medicare beneficiaries with heart failure as: Hypertension, Ischemic Heart Disease, Hyperlipidemia, Anemia, Diabetes, Arthritis, Chronic Kidney Disease, COPD, Atrial Fibrillation and Alzheimer’s Disease/dementia. Care planning around this area should include:
  1. Educating the patient using the teach-back method regarding the importance of reducing lipids to goal.
  2. Teaching the patient regarding the need to keep blood pressure at goal to help slow progression of the disease.
  3. Working with the patient who is also diabetic to understand the need to keep HGA1C at goal

Symptom Measurement See Blueprint Tools page

Recommended Resources