Success with Heart Failure

The Partners Heart Failure Management Program is making strides in ensuring that patients with heart failure—the most common reason for readmission to Partners hospitals—get the outpatient services and education they need to prevent readmission.

“Our mission is to improve the quality of life of heart failure patients and keep them out of the hospital,” said Gilbert Mudge, MD, medical director of the Partners Heart Failure Management Program at BWH and Faulkner Hospital.

Evidence shows that proactive health care, education and outpatient services reduce hospital admissions for heart failure patients. To achieve its mission, the Heart Failure Management Program aims to identify the 2,600 heart failure patients discharged from Partners hospitals each year and connect them with outpatient follow up before they leave the hospital.

“Once a patient is discharged, it becomes substantially more difficult to identify them and connect them with the services they need to manage their care,” said Matthew Quin, BSN, RN, manager of the program at BWH.

The team’s challenge is that patients with heart failure often are admitted to the hospital for other problems and are spread across many units. Heart Failure Referral Coordinator Rebecca White, MS, scans the list of inpatients each morning, pulls the medical charts of those who might have heart failure and speaks to their physicians.

Among the services available to appropriate patients are a telephone health coach program, a telemonitoring program through Partners Home Care or follow up with heart failure nurse practitioner Norma Osborn, NP.

Osborn collaborates with her patients’ primary care providers and general cardiologists to manage heart failure for patients newly diagnosed with the disease, those who have had multiple heart failure-related admissions and those who need intensive monitoring or adjustments in medication dosage.

For more information or to refer a patient, call Rebecca White at ext. 2-6365.