• Medication taking 

Research has found Medication adherence a problem for many patients with heart failure.  Depression is an important contributor to poor medication adherence.  Other factors include cost, mild cognitive impairment, limited health literacy, attitudes about taking medicines and the effect of certain medicines on sexual function, lack of understanding about discharge instructions instructions.

Care Planning around this area should include:

1. A thorough medication reconciliation during the SOC and ROC visit.
2. Referral to MSW if cost or ability to obtain medications is a problem. Identify distant family members who may be involved/willing to cover costs.
3. Assess understanding of all medication actions and side effects, and on subsequent visits adherence to medication schedule.
4. Work with patient to develop self-care behaviors (using teach-back techniques etc.) including decisions and plans to incorporate medication taking into daily activities, obtaining initial and refill prescriptions, and managing a change of routine brought about by appointments, travel and other illnesses.
5. Refer to OT or Speech therapy for cognitive skills if necessary to help with medication adherence.
6. Assess for need to obtain devices such as pill boxes to help with medication adherence.

• Symptom monitoring including weight, edema, fatigue, dyspnea, chest pain, BP, HR.

Research has demonstrated that patients delay for days before seeking care for symptoms of HF.  This delay may be due to a failure to routinely monitor symptoms or an inability to recognize and interpret symptoms when they occur

Care Planning around this area should include:

1. Assess HF symptoms on each visit – vital signs, weight, dyspnea, fatigue, appetite, edema, chest pain, SPO₂, sleep disturbances, dry cough, activity tolerance, dehydration (orthostatic hypotension).           
2. Educate patients/caregivers both verbally and in writing using standardized tools, to improve abilities to recognize, interpret and act on early symptoms. (See tools).  Use teach-back to assess learning.
3. Use Remote Patient Monitoring as a tool for daily, repeated, serial assessments of specific symptoms to reinforce education and support patient/caregivers during this process.
4. Utilize Stoplight or Zone tools to help patients interpret and act on symptom changes.
5. Teach patient/caregiver energy conservation techniques.
6. If oxygen is ordered educate re use and safety.
7. Help patient/caregiver to identify 1-2 achievable goals to help build confidence in self-managing own chronic illness symptoms.

• Dietary Adherence (sodium intake)

Guidelines on the recommended intake of sodium are inconsistent as is the terminology. ACCF/AHA Guidelines for Stages A & B HF recommend 1,500 mg/day. ACCF/AHA Guidelines for Stages C & D HF  state “Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms.” It is noted that sodium intake is high in the general population, so some decrease in intake is appropriate.

Care planning around this area should include:

1. Obtain patient specific sodium restriction orders from the physician if applicable.
2. Use evidence based sodium teaching tools such as Tips to Cut Sodium (Qualidigm) to encourage patients to adhere to prescribed restriction (if any).
3. Make referrals to nutritionist/dietician if needed.
4. Use food from patient’s cupboards to teach patient how to read labels. Evaluate ability to read sodium content by having patient sort high and low sodium foods.
5. Educate aides who are assisting with meal preparation on low and high sodium foods.
6. Consider administering the Newest Vital Sign Tool to determine risk of low health literacy.

• Fluid Restriction

Guidelines recommend a fluid restriction <2 liters/day especially for patients with severe hyponatremia or persistent or recurrent fluid retention despite sodium restriction and use of diuretics. Research has demonstrated that routine fluid restriction in patients with mild to moderate symptoms does not confer clinical benefit.

Care planning around this area should include:

1. Obtain patient specific fluid restriction orders from the physician for appropriate patients.
2. Use evidence based teaching tools to encourage patients/caregivers to adhere to specific restrictions if ordered.
3. For those patients who are Stage D where referral to Palliative Care or Hospice may be appropriate, fluid restriction is not usually helpful.

• Alcohol restriction and Caffeine consumption

Advice to restrict alcohol in HF is traditional despite the fact that few data are available to guide the recommendation. Current guidelines recommend limiting intake of alcohol to no more than 1 to 2 glasses (6 to 8 oz per glass) of wine per day, or no more than 2 glasses for men and 1 for women per day. Persons with alcoholic cardiomyopathy should not drink any alcohol. Moderate coffee consumption (1 to 2 cups per day) does not appear to be harmful to anyone with heart disease.

Care planning around this area should include:

1. Ask about daily alcohol consumption when completing OASIS-C Risk Factor assessment
2. Use consumption recommendations to provide more insight and dialog.

• Weight loss

Dieting may be potentially harmful in patients with HF (Riegel, 2009). Obese persons with HF have a lower mortality and hospitalization rates than patients with normal body mass index. Conversely, weight loss may reflect cachexia, the clinically important and terminal phase of body wasting found as a complication of several chronic illnesses including HF. Although evidence is not conclusive, the consensus is that if BMI is >40 kg/m2, weight loss should be encouraged to bring the BMI down to <40 kg/m2. If BMI is  <30 kg/m2 weight loss should not be encouraged. No recommendations are made for persons with a BMI between 30-40 kg/m2.

Care planning around this area should include:

1. Teach patients and staff to monitor for loss of appetite, unexpected weight loss and muscle wasting.
2. Request dietician referral as needed.
3. Obtain and record patient’s BMI on admission, and determine dietary advice based on BMI.
4. Use the MyPlate Method for teaching appropriate dietary intake.
5. Because weight loss is a powerful independent variable that predicts mortality discussion of advanced care planning and/or hospice referral should be initiated with patients who are cachectic.
6. Teach patients to limit saturated fat, transfats and simple carbohydrates in order to maintain a healthy weight and a normal lipid profile.

• Physical Activity

Routine exercise is a potent way to improve oxygen delivery and decrease inflammation within the arterial wall. It increases peak O₂ uptake in HF and increases coronary flow reserve. Exercise is recommended in patients with current or prior symptoms of HF and reduced LV ejection fraction. In spite of the evidence few persons with HF report engaging in exercise. No universal prescription exists, however, guidelines suggested sustained aerobic activity for 20-30 minutes, 3-5 times a week should be a goal.

Care planning around this area should include:

1. Discuss physical activity program and goals with physician and patient.
2. Refer to PT to establish exercise regimen to improve strength, duration and safety for ADL’s/IADLs
3. Refer to OT for energy conservation techniques and adaptive equipment needs.
4. Utilize modified BORG scale for perceived exertion.  AHA recommendation for patients with heart disease is to use a Borg score and maintain activity level between 13-15 on the scale.
5. Teach simple exercises for limited mobility patients.
6. Consider referral to an outpatient cardiac rehabilitation program post home health discharge

• Smoking Cessation

Tobacco use is strongly associated with risk for increased incident of HF. Nicotine replacement therapy and antidepressants are recommended to help HF patients to quit smoking.

Care planning around this area should include:

1. Address smoking at SOC and ROC when competing OASIS-C M1036 and throughout the episode.
2. Communicate with physician on patient’s readiness to quite smoking.
3. Utilize resources such as “Drug Interactions with Tobacco Smoke and FDA-Approved Medications for Smoking Cessation.
4. Determine which of the many FREE programs clinicians can use with patients.  To be effective, on going coaching support is needed.

• Preventive behaviors (infection prevention)

Routine hand washing, dental health, and maintenance of scheduled immunizations may limit inflammation and infection, which have the potential to cause tissue ischemia in persons with HF.

Care planning around this area should include:

1. Work with patients to motivate them to actively participate in self-care and to be able to associate dental health, prevention of flu and pneumonia or symptom monitoring with prevention of hospitalization or other untoward HF outcomes.
2. Document flu and pneumonia vaccine status on OASIS.

• Nonprescription Medications

Patients are often unaware of the possible interactions with HF therapies and seldom inform their physicians they are using agents such as herbal remedies, alternative medicines and other over-the-counter drugs.

Care planning around this area should include:

1. Routinely ask patients regarding the use of alternative and complementary therapies.
2. Teach patients to maintain a written record of all medications they are taking including over the counter and herbal supplements.
3. NSAIDS such as ibuprofen, indomethacin and naproxen are not recommended in patients with chronic HF. The risk of renal failure and fluid retention is markedly increased in the setting of reduced renal function or ACE-inhibitor therapy.

• Important Co-morbidities

Many patients with heart failure have more than one co-morbidity. ACCF/AHA Heart Failure Guidelines (2013) list the top ten most common among Medicare beneficiaries with heart failure as: Hypertension, Ischemic Heart Disease, Hyperlipidemia, Anemia, Diabetes, Arthritis, Chronic Kidney Disease, COPD, Atrial Fibrillation and Alzheimer’s Disease/dementia.

Care planning around this area should include:

1. Educating the patient using the teach-back method regarding the importance of reducing lipids to goal.
2. Teaching the patient regarding the need to keep blood pressure at goal to help slow progression of the disease.
3. Working with the patient who is also diabetic to understand the need to keep HGA1C at goal

• Pharmacological Symptom Management - Prescription Medications