On Demand: Building a Stronger HF Team Leveraging the Power of Nursing-Presentation Slides

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The document outlines strategies and practical models for strengthening heart failure (HF) care teams, emphasizing the pivotal role of nursing within multidisciplinary frameworks. Heart failure remains a central challenge in cardiovascular health, with current management impeded by clinical inertia, fragmented care, workforce strain, and patient barriers such as health literacy and access issues.<br /><br />A national shift toward value-based outpatient heart failure care, exemplified by the CMS Ambulatory Specialty Model (ASM) starting 2027, underscores the need for structured care coordination and nurse-driven protocols to optimize guideline-directed medical therapy (GDMT), reduce readmissions, and manage costs. Nurses are critical in performance outcomes, care coordination, patient education, and remote management.<br /><br />The Intermountain Health Nevada Heart Failure Program serves as a practical example, evolving from limited scope care to an expanded, team-based model incorporating advanced HF physician oversight, advanced practice providers (APPs), and defined nurse roles. The HF nursing team manages referrals, patient education, symptom management, medication support, scheduling, and financial assistance, supporting outpatient diuresis and asynchronous monitoring programs (e.g., CardioMEMS).<br /><br />Outpatient diuresis programs, fully nurse-driven, enable early intervention for HF exacerbations, reducing ED visits and hospitalizations, yielding cost savings exceeding $1 million annually for Medicare Advantage populations. Remote monitoring and symptom triage tools further enhance care efficiency.<br /><br />Valley Health's Advanced Heart Failure and Cardiomyopathy Center reflects a mature HF care model. Its multidisciplinary staffing—with cardiologists, APCs, RNs, navigators, and remote patient monitoring nurses—operates at top scope, providing medication management, education, advanced care planning, nutritional counseling, and community resource connection. Nurse-led GDMT clinics focus on medication optimization and patient self-care education, aiming for stabilization and “graduation” from intensive management.<br /><br />Key lessons highlight nurse empowerment, triad leadership (providers, operations, nursing), and data-driven outcomes as essential to successful HF program growth and sustainability. Nurses are not merely team members but are drivers of HF care transformation through their holistic, patient-centered expertise.

Keywords

heart failure care

nursing role

multidisciplinary teams

value-based care

CMS Ambulatory Specialty Model

guideline-directed medical therapy

outpatient diuresis

remote patient monitoring

nurse-driven protocols

care coordination