Beating Barriers to Effective Heart Failure Care

Wednesday, December 23rd, 2009
This post was written by Melanie Matthews

Michele Gilbert, education coordinator of the heart failure team and pulmonary hypertension program at Hackensack University Medical Center, discusses different circumstances that lead heart failure patients to not receive proper care management.

There are many barriers to heart failure patients receiving excellent care. Patients have multiple comorbidities. They take lots of medications and experience adverse drug reactions. Dietary compliance issues are a huge problem. There are psychosocial problems, with social isolation and depression being two of the biggest challenges. There are also financial constraints. Heart failure patients are expensive. Medications are costly, and often patients can’t afford them. Patients also have physical limitations. For example, they may have trouble with their eyesight or neuromuscular problems. When I started as a heart failure nurse, I came from a clinical care background. I learned that just because I tell patients to weigh themselves daily doesn’t mean they’re able to see the numbers on the scale. This is also a component of cognitive dysfunction. The instructions we give patients don’t always translate into them being able to care for themselves.

Part of the problem with heart failure case management is the revolving door and our job is to stop it. Patients are getting discharged from the hospital earlier and earlier. Doctors’ offices are not an ideal place for them to follow up on their care or get educational support. Therefore, patients go home not able to understand their medications and manage themselves. As a result, they have an exacerbation and wind up back in the hospital time and time again.

Of all the reasons for heart failure hospital readmissions, half are related to diet non-adherence and drug non-adherence. Often patients truly do not understand, for example, how to manage a daily two-gram sodium diet. We must be specific when we talk to patients. We must ask questions such as, “Who cooks your meals? Who buys your food? How often do you eat out?” We need to explain to patients where the hidden sodium is in their diet. It’s not coming from the salt shaker. Rather, it’s in all the other things in our diet that have too much sodium for patients with heart failure to eat.

With drug plan adherence, it’s very important to explain to patients not only what their medications are and what the dosage is, but also what the pills do. For example, I visited a patient at home once and when I went through her notebooks with her, she thought that her Persantine® was her water pill. Every time she was short of breath, she’d call her doctor who would direct her to take three water pills. Instead, she’d take three Persantine and wind up in pulmonary edema the next morning in the emergency room (ER). It’s extremely important for patients to know what they’re taking and why. Two-word explanations such as “water pill, cholesterol pill, blood pressure pill or heart pill” are usually sufficient.

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