Establishing a Heart Failure Clinic

Informing the Community

HF clinics offer an effective alternative to the current cycle of acute care management. They offer complete patient evaluations, education, regular monitoring, and immediate response to patients’ clinical needs.

In addition, HF clinics offer long-term benefits to patients, families, and the communities they serve. It is expected that each local HF clinic will be a centre of excellence for the clinical management of HF and a resource centre dedicated to improving the lifestyle of HF patients and their families.

Objectives of Heart Failure Clinics

• Improve patient care
• Provide medical care in a timely fashion
• Optimize the use of proven medical therapies
• Educate HF patients about all aspects of their condition
• Improve cardiac function
• Improve quality of life
• Empower patients with the knowledge/capacity to manage heart failure
• Reduce hospital admissions and readmissions
• Reduce morbidity and mortality
• Disseminate the latest information on HF
• Serve the community
• Quality of care assessment

Facility Profile

Clinic Accommodations

• Examination rooms, waiting area, meeting room, offices, exercise room, telemonitoring, telephone follow-up

Equipment

• Office equipment, computers, tables, chairs, blood pressure machines, scales, echocardiograph, treadmill, bikes

Operating Costs

• Part-time cardiologist(s)
• Full-time clinic staff: nurse manager/coordinator, clerical staff
• Telephone costs, Internet access
• Clinic supplies, office supplies

Access/Referral to

• Electrophysiology, CRT, ICD
• Cardiac Surgery
• Transplantation team

HF Clinic Team

The clinics will be Physician-directed and Nurse-managed. The on-staff Cardiologist will perform all initial assessments and examinations, and then develop a treatment plan that will be implemented and managed by the Clinic Nurses.

The Nurse Manager/Clinic Nurse is experienced in cardiology and may have some experience in the outpatient setting. In many settings, Nurses with advanced training are responsible for patient management and the implementation of delegated medical tasks.

Along with the Nurse(s) and the Cardiologist, the clerical staff are considered primary members of the clinic team. They will perform daily administrative duties and assist in data collection and data entry.

Secondary team members who may be affiliated with the clinic on either a part-time, full-time, or referral-only basis include: Pharmacists, Dietitians, Psychologists, Social Workers, and Exercise Physiologists or Physical Therapists as well as EEP Cardiologists and Cardiac Surgeons.

Pharmacists are important members of the clinic’s multidisciplinary team. They provide both patients and staff with information concerning drug interactions, pharmacokinetics of drug action, side-effects of medications, and dosing adjustments required for comorbid conditions. Counselling by a Clinical Pharmacist has been shown to increase patient compliance with medication regimens, resulting in improvements in peripheral edema and physical capacity.^1,6

Referrals to a Registered Dietitian are particularly important for HF patients suffering from comorbid conditions such as diabetes or renal failure. The Dietitian will educate patients about the need for sodium and fluid restriction, assess protein and caloric requirements, and incorporate dietary changes needed to manage comorbid conditions.

Depression, anger, and frustration related to decreased quality of life are common among HF patients, particularly those patients with poor psychosocial adjustment to their situation.² Therefore, referral to a Clinical Psychologist may be necessary. Counselling by a Psychologist can help patients and their family members adjust emotionally to the difficult lifestyle changes required for HF management.

The primary role of the social worker is to develop an individualized living plan for the HF patient. This plan may include making arrangements for food/meals, transportation, home assistance, and providing access to financial assistance. The Social Worker can also assist patients and their family members in finding support groups that provide open discussions of common issues such as work, sexuality, exercise and leisure activities, and the adjustments that must be made to each.

Although HF patients have traditionally been encouraged to modify physical activity, exercise rehabilitation programs have been used successfully to improve the functional capacity of HF patients.^3,4 Therefore, an Exercise Physiologist or Physical Therapist may be affiliated with the clinic to establish an appropriate exercise regimen for the HF patient, provide instruction on exercise limitations, and monitor the exercise program.

In addition to the secondary team members, heart failure clinics may be affiliated with Occupational Therapists, Home-care Providers, Palliative-care Physicians, patient-support groups, transplant teams, members of the clergy, and volunteers. Although not core members of the clinic team, these individuals are highly valued members of a successful clinic program. For example, Home-care Providers are particularly important for the management of older HF patients who may have difficulty performing daily activities such as bathing and sitting in a chair. Also, palliative-care counselling may be required for the emotional well-being of both patients and their family members. Many patients find psychological relief in the ability to talk openly about the mortality associated with heart failure, and preparation for death.^5,6,7,8,9

Patient Selection

Heart failure clinics are outpatient facilities that offer a comprehensive approach to HF management. All patients with suspected and established heart failure (NYHA Classes I to IV) should be eligible for treatment at these clinics. Referrals to the HF clinic are accepted from any source: community Physicians, hospital-based Physicians, and other clinics. Nurse and patient-facilitated referrals for education may also be accepted.

As shown in Figure 2.1, patient education is key to the success of a HF management
program. Education should involve all members of the multidisciplinary clinic team and
should be ongoing.

Figure 2.1. HF management team.

Data Collection

Data collection can be used by heart failure clinics for the following purposes:

1. To monitor patient care issues and outcomes
2. To track public health data
3. To document the need for the clinic
4. To secure funding
5. To answer research questions

References

1. Uretsky BF, Pina I, Quigg RJ, Brill JV, et al. Beyond drug therapy: nonpharmacologic care of the patient with advanced heart failure. Am Heart J 1998;135(Suppl 2):S264-S284.
2. Dracup K, Walden JA, Stevenson LW, Brecht M-L. Quality of life in patients with advanced heart failure. J Heart Lung Transplant 1992;11:273-279.
3. Coats AJS, Adamopoulos S, Radaelli A, et al. Controlled trial of physical training in chronic heart failure. Circulation 1992;85:2119-2131.
4. Sullivan MJ, Higginbotham MB, Cobb FR. Exercise training in patients with severe left ventricular dysfunction. Circulation 1998;78:506-515.
5. Hauptman PJ, Rich MW, Heidenreich PA et al. The Heart Failure Clinic: A consensus statement of the Heart Failure Society of America. J. Card Failure 2008; 14: 801-815.
6. Gattis WA, Hasselblad V. Whellan DJ, O'Connor CM. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team: Results of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) study. Arch. of Internal Medicine 1999;159(16): 1939-1945.
7. Albert NM, Fonarow GC, Yancy CW et al. Influence of dedicated heart failure clinics on delivery of recommended therapies in outpatient cardiology practices: Findings from the Registry to improve the use of Evidence - Based heart Failure Therapies in the Outpatient Setting (Improve HF). Am Heart J 2010; 159:238-44.
8. McAlister FA, Stewart S, Ferrura S, McMurray JJJV. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: A systematic review of randomized trials. J. Am Coll. Cardiol.2004; 44:810-819.
9. Focused Update Incoporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation / American Heart Association Task Force on Practice Guidelines. Circulation 2009;119:391-479.

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