Heart Failure Clinic Resourcing Care Coordination Plan

  • Post category:Uncategorized
  • Reading time:7 mins read

Heart Failure Clinic Resourcing Care Coordination Plan

Readmission after hospitalization due to heart failure is becoming common (Bradley et al., 2018). Readmission leads to higher costs of management of the condition, increasing the number of complications that could have been otherwise manageable (Bradley et al., 2018). Some activities such as patient follow-ups and patient education have proven to be some of the working approaches towards ensuring that there is reduced readmission among heart failure patients (Bradley et al., 2018). Unfortunately, there are fewer comprehensive care plans to help people with heart failure after admissions. This paper provides a care coordination plan to prevent readmission of heart failure patients.

Evidence-based Care Coordination Plan

An evidence-based approach to care emphasizes the use of the best evidence available to manage the patient. It involves the consultation between the patient and the healthcare professional to give patient-centered care that is best suited for the patient. Heart failure has a range of etiologies which means that every patient might need an approach that best suits their etiologies. The causes can be classified broadly into underlying causes, fundamental causes, genetics of cardiomyopathy, and precipitating causes (Canepa et al., 2018). The workup plan for people with heart failure is also diverse, which shows that every patient should be approached differently. Heart failure is a condition that has many symptoms and is characterized by difficulty in management and diagnosis (Halatchev, McDonald & Wu, 2021). Therefore, efforts towards its management require the input of various professionals who are interested in managing its complications and symptoms. A good plan for patients with heart failure should be centered on the patient.

Heart failure management procedure will involve the determination of the patients with the acute and chronic cares of heart failure. Patients with acute heart failure may require faster attention than the patient with the chronic heart failure as their conditions could be worsening at a higher rate as compared to patients with chronic conditions. The treatment of the patients who present to the hospital for the first time will include stabilizing the patient, determining the etiology, and then discharging the patient. On discharge, the patient will be educated on the appropriate management techniques, which include medication, diet, and health-seeking behavior. A good follow-up plan will be established to help in assisting patients before they develop complications from the condition. New admission that is made after the conditions have advanced can be devastating and may prompt frequent readmissions. Therefore, a community reach-out plan and free screening will be in place to ensure that the conditions are diagnosed early.

A good team is necessary to ensure lesser cases of readmissions. The management of the patient will include care coordinators, nutritionists, clinical pharmacists, self-care educators and trainers, group education for the patients, and social workers. Nutritionists will be interested in the patient diet to ensure that they have an acceptable diet for their conditions. The educators and trainers explain the importance of having a different lifestyle to ensure that the life of heart failure patients is prolonged. Pharmacists determine the right medications that will help the patients and the appropriate management for the possible side effects.

The team involved in the management of patients with heart failure is activated during the patient’s index admission. The activation helps the team notice the presence of new patients, their unique risk factors and decide on the most appropriate management approach. Informing the team ensures that the team is prepared for the management of the patient in time. The hospital is expected to have an electronic healthcare system that gives alerts to all the members of the team on the new patients and the probable need of their efforts towards patient management. The electronic health records are also retrieved and are easier to access whenever one wants to handle a patient at a time. The coordination should be possible within a day due to the ease of communication through an electronic system.  The process will include lifetime patient care to ensure that the patient details are always taken care of at a time.

Professional standards in the Care Coordination Plan

Professional standards include the judgment of the clinical safety that is involved by the procedures taken towards offering care to the patients. The nursing profession outlines that having the professional standards put in check is one of the key ways towards ensuring that the service provided is of the required approaches. The advantage of the approaches is that it outlines the specific standards required in offering professional practice services. The important professional standards include the determination of the members’ expectations, promotion of professional practice through self-assessments, and the evaluation of the stakeholders through standard procedures. The standards also help determine the line within which various competencies are supposed to be developed.

The people involved in the management of the patients should be able to meet the characteristics of professionals. The professionals need to have a verifiable mastery of the theoretical knowledge of the cases, have received formal training, and are aware of the punishment against the unethical practice procedures. They are also made to know that they are responsible for the in-competencies in providing care in the most appropriate ways (Rubio-Navarro et al., 2019). The best approaches include determining the extent to which various procedures and approaches that people are likely to choose to be associated with at a particular time. The approaches towards the determination of the right procedures should also have continuous public acceptance.

Professional accountability is also an important segment in ensuring the effectiveness of the procedures (Rubio-Navarro et al., 2019). The professionals in the procedure will have a record to report their follow-up plans and activities. The approach ensures that the professionals involved are accountable and responsible for ensuring a good patient follow-up plan. The approaches include determining how well various types of activities that people choose to get involved in help ensure that there is an improved professional involvement. The process of determination of the success of the coordination plan will depend on the overall patient readmissions. One of the key entities to measure is to determine whether the objectives are achieved. The process includes determining the efforts towards ensuring that the professional objectives are achieved from time to time.

In conclusion, readmission is the major problem in the management of patients with heart failure. Evidence based practise may help in reducing the cases of readmission and the probable complications of heart failure as it focus on determining patient centered approach to care. Nurses, pharmacists, physicians and social workers are some of the key entities in the team to help the patients.  Professionalism is important in the process to ensure the administration of patient care in an appropriate manner.


  • Bradley, S., Rush, P., Wolf, K., Rahmatullah, A., Braun, R., & Samara, M., Bank, A. J., Bergeson, S., Gunderson, W., Strauss, C. E., Witt, S., Hutchinson, M., Tong, T. C., Mueller, D., Eckman, P. & Kubo, S. H. (2018). Improving Value Through Heart Failure Care Coordination: The Allina Health Experience. Journal Of The Minneapolis Heart Institute Foundation2(2), 9-13. https://doi.org/10.21925/mplsheartjournal-d-18-00011
  • Canepa, M., Fonseca, C., Chioncel, O., Laroche, C., Crespo-Leiro, M., & Coats, A. J. S., Mebazaa, A., Piepoli, M. F., Tavazzi, L., Maggioni, A. P., Crespo-Leiro, M., Anker, S., Mebazaa, A., Coats, A., Filippatos, G., Ferrari, R., Maggioni, A. P., Piepoli, M. F., Amir, O. … Thebault, C. R. (2018). Performance of Prognostic Risk Scores in Chronic Heart Failure Patients Enrolled in the European Society of Cardiology Heart Failure Long-Term Registry. JACC: Heart Failure6(6), 452-462. https://doi.org/10.1016/j.jchf.2018.02.001
  • Halatchev, I., McDonald, J., & Wu, W. (2021). A patient-centred, comprehensive model for the care for heart failure: the 360° heart failure centre. Retrieved 10 June 2021, from.http://dx.doi.org/10.1136/openhrt-2019-001221
  • Rubio-Navarro, A., Garcia-Capilla, D., Torralba-Madrid, M., & Rutty, J. (2019). Ethical, legal and professional accountability in emergency nursing practice: An ethnographic observational study. International Emergency Nursing46, 100777. https://doi.org/10.1016/j.ienj.2019.05.003