Follow-up care

Stable patients

Stable CHF patients should be seen at the clinic at regular intervals – every three to six months depending on the severity of the illness. Between visits, certain procedures can be scheduled when required, including interim blood work, checking digitalis levels, and INRs (international normalized ratio).

A viable telemanagement system should be put into place, letting patients know the hours they can telephone the clinic and speak to a clinic nurse for advice and support. A 24-hour pager number should also be publicized for their assistance.

It is very important to communicate clearly with the family and the referring physician so that a proper treatment plan can be implemented and reinforced.

Unstable patients

Unstable patients must be followed daily or weekly. During clinic visits, the following procedures are done: physical assessments, lab assessments, medication adjustment, compliance monitoring, IV diuretics if necessary, and exercise/activity counselling.

The main aim for unstable patients is to minimize hospitalization. Telemanagement for unstable patients is an important factor in achieving this aim. Clinic staff should be prepared to talk with patients as often as needed to ensure that problems are solved before they become exacerbated.

Providing refrigerator magnets or door hangers with the clinic’s telephone and pager numbers will help to ensure patients have the information they need at their fingertips.

Support groups for both stable and unstable patients provide an excellent opportunity for people to learn from experts and network with others. Moreover, support group meetings allow clinic staff to view and assess patients health status during ‘normal’ activity, instead of only in the clinic setting.

Telephone support

Patient telemanagement helps nurse specialists track and manage large number of patients. Its aim is to identify early warning signs and correct patient problems before hospitalization for an acute event occurs. Nurse specialists who track and manage patients by telephone should be equipped with computer decision algorithms to assist in problem solving and foster proactive patient management.

In the absence of many other proactive outpatient initiatives, clinics are advised to consider telephone management of CHF patients. There is indeed evidence that telemanagement alone can reduce the cost of CHF by decreasing hospital admissions and inpatient length of stay when hospitalization is necessary.1

Since many acute CHF episodes are linked to noncompliant behaviour or patients’ poor understanding of their symptoms, inadequate patient self-care often goes unnoticed by caregivers who focus on treatment, not health maintenance.1

By telephoning patients regularly at home, clinic staff identify problems, educate, and provide logistical support for patients. Points to cover during telephone follow-up include:

Problem identification

  • Do you have any physical complaints?
  • Can you identify any symptoms of deconditioning?
  • Have your symptoms worsened or changed suddenly?

Education

  • Discuss dietary restrictions
  • Reinforce effects of medical noncompliance
  • Strongly discourage alcohol use, reiterate benefits of smoking cessation

Logistical support

  • Schedule visits
  • Help arrange transportation to clinic, outpatient hospital services
  • Make referrals to home care, social services or physicians as needed

The two main benefits of telephone management for patients are:1

  1. Patients gain access to nurse specialists trained to identify worsening conditions, and to triage appropriate care modality
  2. Patients living at a distance from hospital need not travel to receive adequate care

References

  1. Cardiology Preeminence Roundtable. Beyond four walls: cost effective management of chronic heart failure. The Advisory Board Company, 1994.
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