Heart Failure Disease Management program

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Care that’s all heart
For heart failure nurses, dedication is their strong suit

When Fern Watson was born in 1916, she was so frail her mother carried her on a pillow and was told, “You’ll never raise that baby.” Fast forward nearly 96 years and Fern is still driving to church and the store — and to play Canasta with friends. Helping keep Fern and other heart failure patients going strong is the Heart Failure Disease Management program at Via Christi Hospital on St. Francis. There, patients learn everything they need to know about their disease and are equipped to start managing their own care.

Only such program in Kansas

Via Christi Heart Failure Disease Management program is the only one of its kind in Kansas, and the only heart failure program in Kansas, Oklahoma or Missouri to have met The Joint Commission’s rigorous standards for disease-specific certification. In April, Via Christi received its fourth consecutive two-year certification from the agency. The Joint Commission surveyor praised the program’s exceptional leadership, resources, commitment and comprehensive approach to both inpatient and outpatient heart failure disease management.

“He suggested we pursue advanced disease-specific certification for our program, which he said could serve as a model for other programs,” says Jennifer Jackson, MD, the program’s medical director.

Extra layer of care

According to the American Heart Association, about 5.7 million adult Americans have heart failure. One-third of the patients hospitalized at Via Christi have heart failure.
“That is a large population of patients who qualify for our unique, multidisciplinary program after their new diagnosis or because of the symptoms they have,” says Jackson.

“We are an extra layer of care for our patients. We are concerned with their quality of life, with helping them live better with their disease and reach their goals.”
The program even helps coordinate patients’ appointments with doctors treating their other ailments.

Education and team support are key —  and unique

Education and consultations — plus being able to get help by phone until 10 p.m., seven days a week — are provided by a team that includes advanced practice nurses and a registered nurse, pharmacist, dietitian and social worker, all led by Jennifer Jackson, MD, the program’s medical director. A statistician keeps track of outcomes data and their receptionist also calls discharged heart failure patients to offer the program’s services.

“Our team concept of care makes us unique,” says Mary Medina, APRN, MSN. “We identify the issue that is affecting the patient’s illness — whether they aren’t aware of their symptoms, can’t afford their medication, or need nutritional guidance or pharmacist support — and come up with an individualized treatment plan. This gives the patient confidence and assurance that they can take care of themselves.”
Cynthia Walker, APRN, MSN, or Medina visits patients when they are hospitalized to explain all elements of the program.

Confidence comes in managing self care

Things had not been going well for quite a while for Larry Cornelison of Douglass, Kan., when Walker came into his room at Via Christi Hospital.

I couldn’t believe it when she started talking to us about all they were going to do for us,” says his wife, Lucretia. “It was as if the weight of the world was lifted from my shoulders and, for the first time in a long time, I had some peace of mind and hope.” 

Larry agrees. “It’s been life-saving. No other words describe it.”

Medina says the Cornelisons’ expectations and spirits were very low when they came into the program, but being the ones in control of Larry’s disease has rejuvenated them both.

“We take care of the whole family, so the patient can stay in their home and avoid readmission to the hospital,” says Walker. “But it’s really the concepts we’re teaching the patients: ‘How do I identify the symptoms, and then what do I do?’”

Every morning, Fern takes her blood pressure while sitting and standing, and weighs herself. If she gains two pounds or her blood pressure is over 150, she calls the office where Medina or Walker listens and makes a recommendation to her. Besides taking her medications, Fern has learned she must limit her fluid intake and eat a low-sodium diet. Each month she takes her chart to her appointment with one of the nurses, where it is reviewed during a consultation and changes, if necessary, are discussed.

“They’re so caring and concerned, they are real jewels,” says Fern of Walker and Medina. “I love them like my own kids. I had my first baby at St. Francis in 1941 and I’ve gone there ever since.”


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