Hi, welcome back to Cardiovascular Nursing Essentials. Today we are going to continue our heart failure module and get into a discussion beginning with treatment. These are my disclosures. So let's talk about the therapies and our goals are really as you would expect. Symptom management, treating or trying to stop or slow down the disease progression, prevent sudden cardiac death, and then the main thing because if we think about the statistics and the mortality rate, we really want to improve their quality of life. And we do have a roadmap, so there's tons of evidence-based management. I did give you guys a lot of links to those. These next couple of slides are really in here for your reference so you understand the class of recommendations. So obviously we're looking at green, which is class one, where we know the benefit outweighs the risk to anything in the red, which is class three, which not quite certain that's debatable on risk benefit. So for your reference and looking at our treatment guidelines, as I mentioned, treatment is dependent on what type of heart failure they have. So we do have the most evidence and roadmap for our HFREF population. But what we need to do even better at is those stage A and stage B as preventing them from getting to heart failure period. And we can do a lot of things like optimal blood pressure and hypertension management to prevent some of that. So I wanted you to be familiar with these guidelines. But we're going to spend most of our time talking about our HFREF population because they are very specific. And as you can see, a lot of class one indications in the management of these patients. And I'm going to tell you the number one thing which will save lives and decrease morbidity and mortality is by 70% is the medications. And the reason is, is it's it's targeting all those hormones and acting as protector of the internal hormonal response. And we're going to talk about all these medications. The second kind of line of defense after medications is really looking at for certain populations. So in our African Americans that have class three and four, they should be on a hydralazine nitrate. On our patients that have lower EFs, less than 35%, we have some therapies, some devices that we should be considering. And then beyond that, in our advanced heart failure patients, do we need to look at some mechanical support and we'll we'll hit those. So when we talk about medications, there's four pillars of standards that we want our patients to be on. Again, these medications save lives, so it's very important. What you should realize is diuretics are not on here. Diuretics should be used obviously, but they are not really going to save lives. It's going to help with volume management and symptoms, but these are the medications that are working internally to to help with symptom management but survival. So the number one medication is an ARNI or Entrestin. We'll talk about that if they can't tolerate that, an ACE or an ARB. So one of those three, not all three, one of those three. One of three beta blockers that we're going to talk about, an MRA, an SGLT2 inhibitor, which is kind of a newer addition and it's actually, we'll talk about this too, indicated for all heart failure patients. So these four pillars are are the foundation and the starting point of treatment for HEF-REF only. These are the ones that are clinically indicated for a reduced EF. So as I said, number one is Entresto, a combination drug. If they cannot afford or tolerate Entresto, an ACE or an ARB will do. One of these three beta blockers. So you'll notice it's bisoprolol, which is a very old beta blocker. You may or may not have given it. It's not very common, but it is indicated. The two most common ones are our carvedilol or Coreg and our metoprolol succinate. And I want you to notice this is metoprolol succinate. Metoprolol tartrate is not on this list. Now they may be on tartrate if they can't tolerate it, but it does not have the morbidity and mortality benefit. So metoprolol succinate is the single S, single once a day or extended release version. And you can just remember that, that it sucks. Succinate sucks to have heart failure. So these are the three that you're looking for. Your MRAs, these are our aldoctone antagonists and they do act like a diuretic, but they have a different function. So they are not actually a diuretic. They do have a diuretic effect. And then your SGLT2 inhibitors, which are recent, you know, initially were targeted for diabetics, but they have been proven effective in all heart failure patients with or without diabetes. So I wanted to show you briefly where we talked about the RAS system and where each of these work. I had a physician tell me, and this made sense, you would not send a football player out on the field without their helmet, their pads, their cleats. So that's what protects the football player. These medications are what protects the heart failure patient. So you can see where our ACE inhibitors work in the RAS system. So we remember angiotensin, that whole cascade increases vasoconstriction. We want to block that. So your ACE inhibitors, they're blocking that conversion of angiotensin one to angiotensin two. So it's going to prevent some of that vasoconstriction. Same thing kind of with your ARNI and your ARBs, just working a little bit further and really trying to promote vasodilation and helping get rid of fluid. Your MRAs, your aldosterone or your aplerinone are here working against aldosterone. So our aldosterone makes us hold on to water and salt. So by blocking that, it's going to help the body get rid of salt and water. So again, I've got a lot of information on medications in here. I'm not going to spend a ton of time going through them. I'll just kind of hit the highlights. But our ARNI is our combination drug of Secubitril and Valsartan. And it's a twice a day medication and we're really trying to increase to get it up to this twice a day, 97 and 103 twice a day. So you'll notice it's got an ARB in it. I will say if we're transitioning from an ACE inhibitor to Entresto, we do have a washout period of 36 hours. So you're going to wait 36 hours, but if you're transitioning from an ARB to Entresto, there's no need because there's already an ARB in the medication. And you can just see this is really working to fight against the vasoconstriction. And so it's got this dual inhibition going on where it's decreasing vasoconstriction and increasing vasodilation. So it's kind of working on two different areas to balance our hormones and patients will really see a benefit in terms of symptoms when they're able to take Entresto. Probably one of the most common things or are prohibitive to taking Entresto is the cost. And I know they're working diligently on that. There are some patient assistance. So if you have some resources, please tap into those. The benefit of Entresto over an ACE or an ARB is a 30% readmission reduction. So you do want to keep that in mind. And these are just some additional kind of notes for you to have as reference in terms of monitoring parameters and things of that nature to keep in mind with these medications. Here's our ACEs. These are easy ones to start with because they tend to be cost effective. They're not too expensive. They're widely available. So you can see a lot of patients on lisinopril. Again, if they cannot tolerate or afford an ARNI, this does have benefits. So we should not discredit this class. Again, your main considerations in these are renal, if they have renal issues or renal failure, that may keep them from being on these. Looking at things like hypotension and risk of angioedema with ACE inhibitors. ARBs, again, can't stress enough that if they're on an ARNI or an ACE or an ARB, they should only be on one of those three, not all three. You're going to see Diavan and Kosar a good bit. So very similar, just looking at renal, looking at electrolytes, things of that nature. Our aldosterone antagonists, generally we will start them on aldactone. Aldoctone works against aldosterone. So it's going to help facilitate getting rid of fluid volume. So we want to make sure we explain that to patients that it does have a diuretic effect, but it is not a diuretic. So some patients will refer to this as their diuretic. Two separate medications, and this has the morbidity and mortality benefit. So it is important that they take this medication too. Some providers are a little bit hesitant to start this at the same time as maybe an ARNI and beta blockers, but it is safe. We should be starting these medications together and increasing them or up titrating. Just more considerations for you. Again, one of the things with aldosterone antagonist is men can actually experience gynecomastia. So they may change them. That's more common with aldactone. So men may be on a plurinone if they're having complaints of that. These are our three beta blockers. We talked through those a good bit, remembering that metoprolisuccinate is the preferred one and really obviously your contraindications and you're looking for a lower heart rate, blood pressure, hypotension. Sometimes in a exacerbation, these are stopped and then restarted when a patient is stabilized. So just making sure from an outpatient perspective, making sure that if it was stopped during the hospitalization, making sure they did get on that at discharge or at follow-up. The neat thing about beta blockers too is we talked about that remodeling and they can actually help reduce remodeling in heart failure. So they can improve a little bit of that functionality of the being able to contract better. So our SGLT2s, these are within the last few years, again, indicated whether the patient has or does not have diabetes. So it does not put them at risk for hypoglycemic episodes and it really functions in the renal tubules and helps to have some really beneficial effects on lowering blood pressure and also can impact weight. So all of our heart failure patients, regardless of EF, should be on one of those. Okay. And then our diuretics. So again, these are not part of the four pillars, but obviously we use diuretics for volume management. Our first line of defense is our loop diuretics. So that's generally, we start with Lasix or furosemide. And what I want you to note about these is the bioavailability. So sometimes we change them from Lasix because when we take a Lasix pill, we're only absorbing about 50% of it. So if somebody's in an exacerbation and their intestines and they're, are inflamed, they're swollen, they're not going to absorb that. So on a good day, they're getting 50%. So it's going to be even less. So that's why sometimes they have to go in for IV Lasix or be switched to one of these other ones, Bumex or Torsamide, because you can see they have much higher bioavailabilities. Patients can also actually develop a resistance to Lasix. So sometimes if a patient's been on it and we're increasing, increasing, and it's just not being effective, we'll switch them to Bumex or Torsamide. If that's not enough, or they have a few days, they have extra fluid, we're trying to keep them out of the hospital. We can add thiazide and thiazide-like diuretics. Probably the most common one is metolazone. We give that in addition to the loop diuretic, and that is really kind of, think of it as a booster. It's going to help really pull off fluid. We don't generally give these on a regular, everyday basis. It should be as indicated, and we do have to be very cautious with electrolytes and renal function if we're giving this. And this is just, again, a diagram reminding us of the renal tubules and where these all work to help pull fluid. And you can, if you remember, we've got your whole glomerulus here, but the loop diuretics work down here in your loop of Henle to pull that fluid out and help the patient excrete it through their urine. So this is just kind of a nice reminder of where at the cellular level we have so much going on in terms of fluid and electrolyte balance and how it all works together. So that's our frontline defense for our HFREF population. Now, these updates that just came out in 22, we're doing a lot, they're doing a lot of studies on therapies for HFREF and HFPEF. So we are starting to see some guidelines, and diuretics obviously for symptom management are on here. Your SGLT2s are a class two indication, and we do see some benefits. So most of our patients, we should be prescribing these SGLT2s. You will see in both your HFMREF and your HFPEF, your ACEs, ARBs, ARNIs, your beta blockers, your MRAs. The difference is, is that they've not been proven beneficial for morbidity and mortality like they have been within HFREF. So again, same as that you saw with HFMREF and HFPEF, again, same medications, just not the evidence to support for morbidity and mortality. So sometimes your patients that are more advanced may be on an inotrope. And when we remember what a positive inotrope is, that's something that increases contractility. And those are usually, the two most common ones are going to be milrinone and dobutamine. And really what these do is they help improve perfusion, decrease congestion, and they kind of augment diuresis so they can help with perfusion to organs. So the caveat is inotropes do not prolong life. They actually are related to a decreased life span. And so this can be more of an end stage therapy and really about symptoms. They can actually improve or get a patient to where they need to be maybe for an LVAD or a transplant. So they can actually be used to kind of bridge that patient there. But this is something that patients go home with and it's a continuous infusion. So dosing does, it's weight-based. So patients will have a home infusion pump and they should have home health for dressing changes. But this really is going to help them with symptom management and just to feel a little bit better. We talked a little bit earlier in the guidelines, we saw indications for ICD and CRT. So I want to talk a little bit about those devices because they're very important. Our primary prevention ICD is really to prevent sudden cardiac death in patients that are at high risk of arrhythmias, lethal arrhythmias. So we're looking at those patients that are low EF, so less than 35%, and really at risk for VT. So the caveat with these is that they have to be on optimal medical therapy for three months to get approved. So you may see patients with a LIFAS, so that external defibrillator to protect them while they're in that waiting period. But if they're on optimal medical therapy for three months and it's not improving anything, they should get a ICD for the prevention of sudden cardiac death. There's also CRT devices or cardiac resynchronization therapy devices, and these are the same thing as a biventricular pacemaker. So really the difference is it improves output, so that's why the reason we call it resynchronization is sometimes what happens is when our EF is low, the heart's irritable, the ventricles actually alternate. So instead of pumping together, you have one then the other. So with the CRT device, the patient has to be EF less than 35%, a left bundle branch or QRS greater than 150, so wide QRS. And what happens is we put the CRT device in, it helps the ventricles beat in sync. So what that does is improve cardiac output and decrease symptoms. Again, they have to be on medical therapy for three months, optimal medical therapy, those four pillars for three months and not show improvement. Some patients, if they're on those therapies for three months, we do see an increase or improvement in their EF and they don't need this, but others that don't do need this. Now patients can have one or the other, but there are some instances where they may have both. So a combined CRT ICD device, it all depends on that specific patient and what they need. There are, hopefully you've seen some more options for remote device management and we're seeing more and more options. And again, all of this does require optimal medical therapy to initiate. So what we're finding is the companies that are making these devices, they also have technology already embedded within the device that gives us some information that can help us see if a patient is actually gaining fluid. So that's going to be things like how often they're actually pacing, their heart rate variability, things like thoracic impedance. And it will tell us if a patient is actually gaining fluid and we can be proactive in their management through a device that is already in place. So it does require somebody to watch and manage those patients, but that capability is there. So I imagine if you have a ICD clinic or remote clinic, you probably have access to that data. But unfortunately, again, it can be a challenge to make sure you have staff to be able to monitor that data. Another device system is the CardioMan system. This is not a therapeutic device, but it helps us to monitor PA pressure. So basically you have this little sensor that gets placed and what we do is send patients home with this equipment. You can see the kind of tennis racket looking one is for hospital, but the patients go home with this pillow and they lay on that pillow every day for a short period of time and it gives us their PA pressures, the waves, the waveforms, and the readings. And we can actually see increases in fluid before a patient can feel them or we see any weight changes. So we can make medication adjustments and really keep their volume status where they need to be and prevent hospitalizations. HeartLogic is one of those devices that's embedded already in a pacemaker or ICD and again it looks at different components for signs of fluid gain. So that is looking at heart sounds, thoracic impedance, respiratory rate, what their heart rate's doing at night, and their activity level. And it creates a score so someone can monitor that and if they're seeing increasing scores or calls for concern, they can call that patient. You can do an assessment over the phone and communicate with the provider to see if there's anything we need to do to help manage that patient's fluid. The next devices are actually some therapeutic devices and are helping patients to feel better. So these are really exciting in the space. The first one is our CVRx Varostim Neo and you can see it looks like a pacemaker. It's generally put on the other side of the chest, but these patients are patients that have NYHA class 3 or 2 heart failure and they're already receiving GDMT. They do have to have an EF of less than 35% and an elevated pro BMP. But basically, this actually, the device is implanted to the outside of the baroreceptors on the carotid artery. So generally, it's put in by a vascular surgeon. Right now, it's a cut down approach. They are looking at some other approaches, but you can kind of think of it as a mechanical beta blocker. So it's working to activate the parasympathetic nervous system. So it's actually decreasing heart rate, decreasing blood pressure by vasodilation. It's really combating that sympathetic response. These patients get implanted. It's an outpatient procedure. Now they do have to go back to their heart failure physician's office and they'll get their settings changed about once every month until they reach what's determined to be their optimal settings. But a lot of these patients are able to be a lot more active once they get to those optimal settings and are feeling much better with this device. So it's a great option for our patients. The other kind of recent device is the impulse dynamics optimizer. Again, you can see it looks like a pacemaker, but this one has leads that go actually into the septal wall and CCM actually is a cardiac contractility modulation. So it helps kind of the effectiveness of the heart to contract. Again, these are, there are specific criteria. So we're looking for a lower EF. It's, it does have a little bit more of a range. So 25 to 45% on that EF class three, they do need to be symptomatic again, despite optimal guideline therapies. But these are really have been proven beneficial in improving quality of life through six minute walks, functional status. So these are some other good options for these patients. These are also being trialed for higher EF, so greater than 45%. So hopefully in the next couple of years, we'll see what the research shows and there's potential for broader range of EF. So we've talked a lot about the medications and the devices, but as you all know, we know that lifestyle and modifications are a huge component of this. So it's important that we're hitting all the aspects of care, including diet, fluid balance, salt intake, what's their activity level and how do they balance that when they don't feel well? Are they managing their stress? This is a huge, huge toll on not just the patients, but also their family. Are all of them managing and addressing the psychosocial aspect of it? And how can we help them set those achievable, maintainable goals? So some of our non-pharmacological interventions, I think that get overlooked are our vaccinations. So it is important that we are offering flu, COVID, pneumococcal vaccines because these patients, they're at higher risk, but of course, if they do get one of those, then they could actually lose some more heart function. So it can in the long run really be beneficial for them to be protected. We've seen with COVID and other viruses, the cardiomyopathies. So we really want to make sure they understand the importance of vaccinations and that they have the option to receive them if they have not. Something we hear about all the time is our dietary and our patients get really frustrated with the salt restrictions. So I know there are guidelines. The standard is less than 2000 milligrams a day. A couple of years ago, they said two to three milligrams a day. And the reason they give a range is actually was more achievable for patients to meet a range instead of being constricted so much. So this helped them break it down into more kind of understandable, like I can have a thousand milligrams per meal. And they found that patients weren't having kind of as many exacerbations. So I think when you're talking about sodium and incorporating, how do you balance that? It is important, but making it manageable so that a patient can sustain and maintain that balance. So something to consider. We've talked about physical activity numerous times and how good it is to move the body and improve quality of life. I do want to put in a little bit of a flag for cardiac rehab. I know sometimes the criteria can be very stringent, especially with our Medicare, Medicaid population. But if we can link them to cardiac rehab, that's really beneficial physically and mentally. And they can have some social support and networking there. So we want to educate our patients on how to identify symptoms early. This is one of the most important things that you can teach them so that they're checking in with themselves on a daily basis. This is an example of a tool. This is what AHA uses. If you don't have some sort of format, like a traffic light, a stoplight, or something like this, I would encourage you to look into that. And really, it's an easy way to remind your patients to check in with themselves every day and to contact their heart failure provider if they're noticing signs of increasing fluid. So what I would say is what we have to do is stress all the things, right? And one of those things is weights and instructing them how to do it and what they're looking for. So they can weigh themselves, but they need to do it the right way. And so the best way to do that is to do it the same time every day. So generally making it part of their morning routine, getting up, going to the restroom, stepping on that scale the same time, the same amount of clothes, and then writing it down and comparing it to the day before. Train your patients that if they're gaining three pounds or more overnight or five pounds in a week, that's a red flag. So we want them to do this every day. I've told patients put this, we've given magnets or laminate them, put it on your bathroom mirror so it's a visual cue. We want them to check in. So the goal is for them to be in that green zone and that's really for them at their baseline, okay? It may not be no shortness of breath, but it's no extra shortness of breath, no extra swelling, no extra weight gain, no chest pain. This is where they want to be. That kind of raise the bell areas, that yellow caution, and this is when we want them reaching out to their office, their doctor's office, specifically their heart failure provider. This is somebody that may have worsening shortness of breath with activity, that weight gain we talked about, increased swelling, maybe they're trouble sleeping, sometimes they just have a feeling of being off. So sometimes you can use your clinical skills and assess and we we may bump up their diuretics a bit and then keep them out of the hospital. If they're calling and it's too late, like they're complaining of chest pain, altered mental status, they cannot catch their breath, obviously those are things that bypass the office and go straight to the emergency room or 911. We have talked about those kind of triage scenarios, so if you need a refresher on that, please check that module out. But this is a one of the most beneficial education tools you can provide to your patients. So we referenced a little bit about advanced heart failure and there is a difference between kind of general heart failure and advanced heart failure. So what happens when a patient has that systolic heart failure but they're continuing to decline? Because remember heart failure is a progressive chronic disease, so they will continue to decline. So advanced heart failure is that kind of top sickest of the sick population within heart failure and it may be time to consider some mechanical support through an LVAD or a heart transplant. And what I'm going to share is some guidelines of when you want to consider patients for advanced. Now ultimately it is the provider's decision, but I want to share with you because you may encounter patients that actually need to be referred to an advanced heart failure specialist and you can get them there. So these are those patients, again they're on optimal guideline directed medical therapy, but they're not doing well. So they still have persistent symptoms, so that's really that class three or four. They have severe cardiac dysfunction, so that's the lower EF, usually less than 30 percent. Maybe have RV failure, so you want to really look at that clinical picture. Lots of hospitalizations, so maybe they are having to be hospitalized for decongestion with IVs, IV diuretics, maybe they're needing inotros because they're not perfusing, maybe they're having arrhythmias. All of those are indications that they're advancing or progressing. And then there are some other tests in terms of functionality, so six minute walk or VO2 that can indicate further digression in the disease. There are a few tools and acronyms, so I need help, this can help you identify patients. Some systems do use this as referring criteria, again you can see what those things are that are good triggers for referrals. And then there is also the Intermax registry, which gives them an Intermax level, which is associated with their basically their NYHA class and helps kind of give you that picture of where they're at in their advanced heart failure continuum. So it really looks at hemodynamic profiles and functional capacity to give them that level. So we've had a lot of information and there's a lot of different ways to get patients heart failure programs kind of set up and have different pathways within your organization. So I want to talk about that a little bit. You may have a well-established program, you may not have one, or you may be somewhere in the middle. But our patients, no matter if you work on a general cardiac floor, a telemetry floor, an outpatient cardiology primary care, we're going to meet our heart failure patients because they hit everywhere. So they're in our ED, they're in our hospitals, they're across the board. And there's a multitude of ways that organizations opt to treat these patients, as you can see. So there's different approaches. You know, we can do inpatient programs, we can do outpatient, we can do a combination of the two. And really, if we're focusing on an inpatient process, we're really catching a patient after they're admitted for hospitalization. So instead of being proactive, we're being more reactive. And unfortunately, I think just the state of the way things are, that's how our system has set us up. And I hope we can get to a more proactive approach. But really, this is a kind of triggered inpatient admission, utilizing nurse navigators and APPs to provide education, make sure that they are on the right medications, working with their providers to make sure they have that guideline directed medical therapy, making sure that they're connected with the appropriate outpatient plan, do they have their follow-up appointment, do they need some support services, things of that nature. And then there are ways to refer patients to heart failure clinics for being established there as well. The challenge with all these different models is and locations of treating these patients obviously is variations in care. We want to make sure as we've learned the complexities of caring for these patients, the multitude of options that we're addressing those and extending quality of life for these these patients. So we do have hospital-owned programs, we have practice-owned, we've got advanced therapy, so there's all sorts of options. So I want to talk through those a little bit and see where you are and see if there's opportunity within your organization to work on this a bit. So for sites that don't have a formal heart failure program, obviously this is probably the hardest or most challenging because we're supporting our patients through individual providers. It could be primary care, cardiology, hospitalists. It's just a very, like I said, reactive model and so that leaves a lot of gaps. There's not really this cohesive strategy, there's not really the coordination of efforts, and so it's a very challenging model to live in, not for just patients but for providers and care teams. Our hospital-owned programs, typically, I mean these were generally born out of our readmission reduction program by CMS and those requirements. So these programs tend to utilize RNs and APPs to manage our patients with the oversight of a medical director or physician, and we do have alternate methods now, telephone, face-to-face, virtual visits, or in-person visits. It can be a transitional care model, so it could be that they're seeing these patients for that period of time after they left the hospital, but it can be a very volatile business model because of the amount it costs to fund the program. It can be a little bit disconnected from our community providers and have challenges in terms of long-term management funding because it is a very expensive model, and no matter how effective these teams are and how hard they work, not taking away from that, we do know that the funds have to be there to be able to establish those and pay for those positions. So it can come up a lot in terms of sustainability from a financial perspective. Our practice-owned heart failure programs are usually born out of the cardiology practices who see a need for it, and they embed the heart failure clinic within their clinic. We've seen transitional and long-term models. We've seen effectiveness out of both, and they're generally more of a shared care model, so they're really managing the heart failure and the patient still seeing their cardiologist for all their other cardiology issues. Challenges, it's only touching a subset of heart failure patients, so not the whole population and masses, so you have to be targeted because you're generally limited by resources. Again, it's an expensive model because you do want to have a multitude of specialties or specialists within the clinics, so your social workers, pharmacists, dieticians, because we're trying to address so many different aspects. Shared care does get a little bit challenging, so some patients get attached to heart failure clinics and don't want to see their general cardiologist, and then that can create some tension internally, so shared care models are great in theory, but sometimes execution is hard. Again, funding, the fees and co-pays even with patients, depending on the models, can be high, so that can be another issue, and then access, limited access, not having the amount for patients can be a challenge too. Our advanced heart failure programs, again, we talked about what advanced heart failure patients are, and these kind of programs are really looking at those stage C and D, those patients that are progressing, and are they eligible for VADs and transplants. They take a lot of community resources, they take a lot of internal resources, and it definitely relies on that shared care program, so these are very beneficial, and a lot of programs are trying to establish them, and there is a need in most communities to do these, but I encourage you, if you're not familiar within your organization, to do some digging and see what your program is set up, or if there's not, and is there opportunity to discuss that. So, what does a standard look like for a program of excellence? We know that it has to be consistent, and there needs to be purposeful standardization to meet the demands and the needs of these patients, and it has to span the entire continuum, so we can't be focused on inpatient and not the outpatient. We need to look at all of the whole continuum, from primary care to our cardiology offices, to the ED, to urgent cares, transition care clinics, and then beyond that, our home health programs and our SNFs and SARs, so there's a lot of touch points that have to be organized in order to meet these needs, so the care has to touch not just all of those places on the continuum, but the different models and the different stages of where those patients are, so is it referrals? How are we getting our patients to the right provider? What is our diagnosis process look like? Are we following those guidelines? What's the multidisciplinary evaluation? So, we know that it's more than just a cardiology workup. What's social care? What's their psychosocial support? What finance issues? Pharmacies involved? So, it's a team-based, truly team-based structure. What's the process going to look like for further workup? How are we going to intervene? What do we have set up so we can intervene before a patient needs to go to the ED? How are we going to follow them after a hospitalization? So, there's so many things that have to be considered as we're building these programs, and the only way to do that is through a collaborative effort. We have to have a truly team-based care model for it to sustain. We can't rely on one or two people to carry this on their shoulders and expect it to be effective. It has to be really a system-wide transformation, and that's how we've seen success in organizations that have been effective in serving this population. So, from an organizational standpoint, that means alignment from our physician leadership and their clinical strategy to our governance and our structure through performance management, meaning quality metrics and goals and strategies there. What is our clinical care strategy? Do we have pathways? How are we supporting care coordination efforts and those social determinants of health, and then how are we operating it? How are we delivering this model, and how are we marketing it not just internally but also externally to the community, and I will say that internal marketing strategy is important because if your program does not have support of the internal physicians and leadership, it won't be successful. So, it's an internal and an external focus, and really there's a lot of elements, as you can see, that come into play, but you really want to work on standardizing where you can and where it will be most purposeful, and that's really in looking at your program, like what's the scope, how far, who's your target, and what are your performance metrics going to be that guide how you deliver care, where you need to make improvements. Your emergency department, looking at those patterns of discharge and disposition, are they getting admitted every time, or is there a way we can look at some alternate routes? Does every heart failure patient have to get admitted? No, but how can you set up some pathways to work with your cardiology offices, your heart failure clinics, to offset some of those admissions? How are you identifying your patients? How are you documenting? It's a large care team, so everybody has to be able to read the notes and be able to pick up where the last person left off. What are your protocols and pathways, care management strategies, so that we're delivering expedited care and that we're following compliance to make sure we're following all those standards that have to take place, and that's true for our diagnostic and our procedures as well for this population. Our operational elements, again, are just as important, so we have tools. How are we leveraging our EHR to support these efforts? They can be very helpful in standardizing processes like order sets, discharge notes, things of that nature. What are those handoffs and transition processes within your organization, say from hospital admission to that follow-up appointment, or ED to the clinic? Establishing those kind of communication patterns and policies. Establishing a heart failure clinic, that's a lot of work, but it can be very beneficial, and how are you getting patients there? Performance management systems and processes are really what data is driving your decisions and areas of focus. Are you looking at readmission and length of stay data, registry data, really helping your team hone in and see where the focus needs to be, and then what does the care team look like? When I say care team, yes, you have your heart failure core team, but you also need to engage your clinical cardiology, primary care, hospital medicine, and what's your communication and collaboration effort going to be, so making sure we have all those components. Obviously, patient first. We're really focused on that patient. We do want to drive initiatives through providers, but they're limited, so we need to make things as easy as we can and filter, use our nurses, our APPs, and our care team members to top of their scope and push the critical things up to those providers. Making things standard, having those policies in process will help deliver patient-focused, high-quality care, and really understanding where the main barriers are. We know there's a lot of barriers because there's a lot of components. There's medical barriers. There's things like altered mental status or cognitive impairment, meaning the patient can't retain the education or the information. Is there depression or substance abuse that is impeding that? Maybe they don't have the family support. Other things like food insecurities, they don't have the money or access to healthy foods. Is there some social issues like domestic violence or homelessness? There's a multitude of things. One of the things we really promote is the use of a nurse navigator. And I call them the glue. They're really connecting all the dots, being the kind of the, not just the expert, but connecting the patient to those providers and being the resource, not for just the patients, but those clinical team members. They serve as an educator, a quality improvement champion, consultants. They're just really beneficial to have on your teams, and they can profoundly impact patient care, even provider satisfaction, because they're helping to be the person that's communicating and getting all these critical things done and making sure we're addressing everything that needs to be addressed for these patients. And as you can see, there's a lot of objectives that they have, and they work very diligently. Historically, they've been inpatient focused, and so they really work on identifying needs at admission and helping address some of those discharge needs, going deeper into education and enhancing patient learning where it's needed, trying to be really effective in communicating needs to care teams and to providers and patients so everybody's on the same page, ensuring that appropriate post-discharge follow-up. They do a lot around quality initiatives. Again, we talked about data and how that drives programs, so they're heavily involved in that and really effective in reducing readmissions, length of stay, and improving those registry numbers. And again, it's not just about the numbers, but we want to make sure the efforts we are providing are driving improvement in our clinical outcomes to help those patients, so that's why those numbers are so important. So when we're looking at these different models in transition of care, so if they're discharged from the hospital, our nurse navigators and teams can sometimes connect them with a transition of care model, and these have been really helpful in that time frame of recent discharge, so where they're really vulnerable. In these clinics and programs, sometimes they're remote. They can be just a phone call or virtual visit where they access that discharge record, do some med reconciliation, heavy on patient education, and making sure that they're feeling okay, they're not getting into any issues, and establishing and confirming their follow-up plan. And these programs rely heavily on protocols and tools, so pathways, maybe home health programs, maybe working with skilled nursing facilities to set something up, but these are kind of those models that get our patients through that very vulnerable period once they're discharged from the hospital. And our heart failure clinics, as we said, they can be embedded in a cardiology clinic, they can be standalone, there are different models, but it's very beneficial because it is resource-intense, addressing all those needs of the patient. So generally, a lot of our clinics are APP-led, so nurse practitioner PA with support and oversight by a medical director, but the other crucial team members that are just as vital are those heart failure nurses, the pharmacists, social work, it could be exercise, I've seen some with exercise physiologists, we've got MAs or clerical support staff that are very important, so it definitely takes a village. Again, I urge you to see what your resources are, if you have a program in your organization, and if you do, it'd be great to try to spend some time and shadow with those so you're familiar with what their offerings are and how you can connect patients there appropriately. And then if you have a specific interest in heart failure, there are a lot of certifications, I'd say organizations tend to do the joint commission heart failure certification, ACC has a certification, so this is just some information if the organization is interested in that. And then if you as a nurse are really interested, there are opportunities, especially in that nurse navigator world, I encourage you to look into that if that's something that you have a passion about. There are some organizations that are highly recognized and they both have great learning opportunities, so AAHFN is for nurses only, it's great, they have great education opportunities and conferences and a network to other heart failure nurses, also opportunity for certification, so I always promote that for individuals who want to further their education. And then HFSA is all heart failure providers, they have great education information and conferences as well, so I know today we went through a lot of information and I hope that you will continue to reference it and learn more on your journey. If you have any questions about any of the content or the readings, please don't hesitate to reach out at academy at medaxium.com. Thanks for joining me today.

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