Helping Patients Manage Heart Failure

Thanks to the intensive outpatient care and education provided by Norma Osborn, NP, in conjunction with a cardiologist and a primary care physician, Ellamae Hendrix, 82, has been successfully managing her chronic heart failure without being admitted to the hospital.

Her last admission to BWH was more than two years ago, and that’s “good news,” says the patient, who knows how to take care of her heart because of Osborn’s teaching.

Heart failure is the most common reason patients are readmitted to Partners hospitals. To prevent readmission and improve patients’ quality of life, the Partners Heart Failure Management Program is ensuring these patients get the outpatient services and education they need.

“We’re very excited to have a dedicated group of people working towards maintaining the health of the heart failure population,” said program manager Matthew Quin, BSN, RN. “This program enables patients to enjoy a higher quality of life in the comfort of their own homes, unrestricted by multiple hospital stays.”

The program aims to identify the 2,600 heart failure patients discharged from Partners hospitals each year and connect them with appropriate 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,” Quin said.

To achieve this goal, Rebecca White, MS, heart failure referral coordinator, scans the list of inpatients each morning, pulls the medical charts of those who may have heart failure and speaks to their physicians. If appropriate, White can connect patients with services such as a telephone health coach program, a telemonitoring program through Partners Home Care or follow up with Osborn.

Osborn collaborates with 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.

Educating patients is a major component of Osborn’s work. “Self care requires developing habits such as following a low-salt diet, limiting fluid intake and taking medications such as diuretics, beta blockers and ace inhibitors,” she said.

If a patient isn’t taking care of himself or herself, Osborn gets to the heart of the problem. “Part of my job as a nurse is to understand what patients’ lives are like and work with them to figure out how they can integrate good heart health self care activities into their daily routines,” she said.

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