Table 1. Heart Failure in the Post-Acute and Long-Term Care Setting

• HF is one of the top causes of 30-day hospital readmissions. Factors such as inadequate staff training and education, provider unavailability and failure to adhere to standard guidelines for care all contribute to increased rate. Randomized control trials of Skilled Nursing Facilities with a designated program focused on, and applied interventions for, HF readmission prevention and reduction have proven to reduce 30-day readmissions rates by 20% to 40%.
• HF is a complex clinical syndrome that results from any structural or functional disorder that impairs the ability of the ventricles to fill with or eject blood at a rate commensurate with the body’s needs.
  • Differentiation of patients with HF based on left ventricular ejection fraction (LVEF) is important due to different underlying etiologies, demographics,
    co-morbidities and response to therapies. Consequently HF has been newly classified into 3 subdvisions – HF with preserved ejection fraction (HFpEF) ≥50%, HF with mid-range ejection fraction (HFmrEF) 40–49% and HF with reduced ejection fraction (HFrEF) ≤40%.
• The AHA prevalence statistics show:
  • For the 60–79 year-old age group, the following have heart failure:
    7.8% of men; 4.5% of women.
  • For the 80 years and older age group, the following have heart failure:
    8.6% of men; 11.5% of women.
  • Characteristically, patients with HF typically also have hypertension as well as other medical comorbidities, including chronic obstructive pulmonary disease, chronic kidney disease, hyponatremia, and hematologic abnormalities.
• Clinically, patients with preserved systolic function HFpEF are older and are more likely to be female, to have significant hypertension, and to have less coronary artery disease.

STEP 1: Identify Individuals With a History of HF

• Most patients admitted to a Post-Acute/Long-Term Care (PA/LTC)
  facility with a history of HF will have an established diagnosis of HF recorded in the transfer summary.
• Additional patients with HF may be identified by using medication reconciliation.
  • The transfer summary and other referral data as well as the facility clinical record are helpful in identifying patients with a history of heart failure.
  • Copies of all laboratory tests (See Appendix 1 in full text); electrocardiogram, echocardiogram, and catheterization reports; cardiology consultation reports; and chest x-ray reports may be particularly useful when the patient is transferred from the hospital to the PA/LTC facility.
  • Look for documentation that suggests or supports a diagnosis of coronary artery disease, diabetes, or hypertension. In addition, look for evidence of previous treatment of or hospitalization for heart failure.

STEP 2: Identify Individuals Who Currently Have Symptoms of HF

Table 2. Symptoms That May Suggest HF

• Abdominal distention
• Acute confusional state, delirium
• Anorexia
• Anxiety or restlessness
• Decline in functional status
• Decreased exercise tolerance
• Dizziness
• Dyspnea at rest
• Dyspnea on exertion
• Fatigue
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Unexplained cough or wheezing, especially at night

Table 3. Signs That May Suggest HF

• Ascites or increased abdominal girth
• Increased jugular venous pressure
• Bilateral lower extremity edema or sacral edema if bed bound
• Positive hepatojugular reflux
• Rales on lung exam
• Tachycardia, tachypnea, hypotension, or hypoxia
• Third heart sound (S3)
• Weight gain

Table 4. A Screening Tool for Caregivers (A NEW LEAF)

STEP 3: Identify and Assess for Risk Factors

Table 5. Common Risk Factors for HF Exacerbation

• Anemia (severe anemia of new onset or rapidly progressive anemia)
• Arrhythmia (e.g., atrial fibrillation)
• Chronic obstructive pulmonary disease
• Coronary artery disease (angina or myocardial infarction)
• Fever
• Increased salt intake
• Infection
• Medication nonadherence
• Medications (e.g., antiarrhythmic drugs, calcium channel blockers, Megestrol Acetate, NSAIDs, Doxorubicin, thiazolidinediones)
• Pulmonary embolism
• Pulmonary hypertension
• Renal failure
• Sleep-disordered breathing
• Thyroid disease (hypo- or hyperthyroidism)
• Uncontrolled hypertension
• Valvular heart disease (e.g., aortic stenosis, mitral regurgitation)

Table 6. Clinical Events That Can Help to Identify Patients With Advanced HF

• Repeated (2 or more) hospitalizations or emergency department visits for HF in the past year
• Progressive deterioration in renal function (e.g., rise in BUN and Creatinine)
• Weight loss without other cause (e.g., cardiac cachexia)
• Intolerance to ACE inhibitors owing to hypotension or worsening renal function
• Intolerance to beta-blockers owing to worsening HF or hypotension
• Frequent systolic blood pressure <90 mm Hg
• Persistent dyspnea with dressing or bathing requiring rest
• Inability to walk one block on level ground owing to dyspnea or fatigue
• Recent need to escalate diuretics to maintain volume status, often reaching daily Furosemide equivalent dose >160 mg/d, use of supplemental Metolazone therapy, or both
• Progressive decline in serum sodium, usually to <133 mEq/L
• Frequent ICD shocks

Table 7. Indicators of Poor Cardiac Prognosis

• Aortic stenosis
• Cachexia
• High B-type natriuretic peptides
• Low left ventricular ejection fraction
• Low serum sodium
• Marked left ventricular dilation
• Progressive renal dysfunction
• Syncope and near-syncope
• Valvular regurgitation
• Ventricular arrhythmias

STEP 4: Decide if a Workup is Appropriate

• Diagnostic workup should provide information for prognostication and guide treatment.

STEP 5: Perform Appropriate Imaging Studies to Help to Elucidate the Etiology or Severity of HF

Table 8. Imaging for HF

STEP 6: Decide if Interventions for Modifiable Risk Factors and Treatment of Potentially Reversible Etiologies Are Appropriate

• Reasons for performing or not performing a workup, for undertaking or not undertaking a treatment, or sending a patient to the hospital versus treating the patient at the PA/LTC facility should be documented in the medical record.

Table 9. New York Heart Association Heart Failure

STEP 7: Develop an Individualized Care Plan and Define Treatment Goals

The individualized care plan for HF management may result in any one or more of the following:

• Improved quality of life
• Increased tolerance to activity and exercise
• Symptom relief
• Prevention of exacerbations
• Reduced hospitalizations and emergency department visits
• Prolongation of life to the extent possible
• Better articulation by the patient and family of their preferences for end-of-life care (hospice)

STEP 8: Optimize Treatment for Comorbid and Contributing Factors as Well as Cardiac Factors as Appropriate

• Pharmacologic as well as non-pharmacologic interventions should be considered.

Implantable Cardioverter-Defibrillators (ICD) and Cardiac Resynchronization Therapy (CRT)

• ICD are indicated to reduce the risk of sudden death in patients with LVEF <35% despite optimal medical therapy. ICD will not ameliorate symptoms but are beneficial to prolong life.

Table 10. Adjunctive Treatments