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Disease Management Guidelines Congestive Heart Failure

Disease Management Guidelines Congestive Heart Failure

Disease Management Guidelines Congestive Heart

Disease Management Guidelines A working tool intended to assist with the development of an individualized comprehensive plan of care Congestive Heart Failure Goal: Optimize Management of Congestive Heart Failure and Minimize Risk of Debilitating Complications Action Steps: 9 CM will: Explore and provide MEMBER/caregivers with information on Congestive Heart Failure (CHF) resources such as the American Heart Association, local support groups, and area CHF management programs. Facilitate an IDT with RN, PT, Dietitian, Diabetes Educator, Member, PCA, Informal Caregivers, and/or other providers as deemed appropriate and available to assess disease status, safety/supervision needs, program and community appropriateness, and to develop an individualized program of CHF management Provide ____ home visits (frequency to be determined by MEMBER need) to: _ Assess medical, psychosocial, and economic needs and explore needed resources _ Monitor and evaluate MEMBER adherence and outcomes to include, but not limited to review of: ▪ Medications ▪ Functional abilities ▪ Daily weight logs ▪ Exercise logs/PT Plan ▪ Food diary ▪ Vital signs (wt, BP, and pulse) log ▪ Mental Health ▪ Caregiver stability ▪ Life Transition Planning ▪ Immunizations ▪ Regular medical visits _ Evaluate effectiveness of plan Disease Management GuidelinesCongestive Heart Failure 4.11.2003 © 2003 Long Term Care Authority of Tulsa – Center for Health Care Concepts Page 1 of 5

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