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Care Coordination and Transitions in Heart Failure Care. Health Services Research & Development Online Forum

Heidenreich PA. Care Coordination and Transitions in Heart Failure Care. Health Services Research & Development Online Forum. 2014 Aug 19.




Abstract:

Heart failure is one of the medical conditions most likely to benefit from care coordination through times of patient transition. As a chronic condition characterized by periodic hospitalizations, heart failure involves frequent care site transitions accompanied by important changes in management, for example, new medications or dosage changes. Heart failure patients may experience transitions between different levels of inpatient care (e.g., acute care, long-term skilled nursing care), between inpatient and outpatient care, and between different levels of outpatient care (e.g., to advanced heart failure care). While transitions also can occur on the home front (e.g., from not working to returning to work), few of those with heart failure symptoms are working given their older age. Those heart failure patients who continue working may experience significant fatigue and risk of arrhythmia that require modification of work duties. For those with advanced heart failure, the appropriate timing of any transition to hospice is difficult to determine given the uncertainty in prognosis....





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