Northwest Indiana is challenged with a disproportionate share of heart failure (HF) patients. HF is among the top diagnoses for admission and readmission, presenting the potential for huge financial penalties for hospitals. You might be thinking, that sounds like what most healthcare organizations in the country are working on.

This is a challenging time with many opportunities to work on HF chronic disease management. The latest ACC/AHA HF guidelines provide a "playbook" for the HF care team. Like many hospitals, Methodist Hospitals, Inc. in Gary/Merrillville, IN, is proactively implementing many of these strategies. Last fall, a cardiovascular nurse navigator program was started, with one registered nurse (RN) "navigator" dedicated to each of two hospital campuses. This position is dedicated to educating, coaching and guiding patients and their care givers to navigate a system that can seem very complicated and confusing. The first of two HF clinics opened in December 2016. It is a clinic led by nurses, staffed with a nurse practitioner and an RN who work collaboratively with the navigators to provide an in-depth extension of the education that began in the hospital, HF medication titration and facilitated care transitions.

HF education begins by providing patients and their caregivers with self-management skills. Patients become active participants in their HF management. Although the clinic and navigator programs are new, the organization and patients can see improved efficiency in care delivery, reduced readmissions and improved quality of life. The second HF clinic is scheduled to open in early Fall 2017.

Recently, Methodist Hospitals Heart & Vascular Institute hosted simultaneous HF meetings – one for providers and one for the public. The Third Annual Heart Failure Symposium was attended by more than 150 health care providers from numerous hospitals, clinics and universities in Northwest Indiana and the Chicago area. Topics such as advanced HF management, disparities in HF care, sleep and the failing heart, mobile technologies in care management and the role of the heart team in navigating transitions and care coordination were presented by experts in the field.

Concurrently, in an adjacent room, a conference for patients and community members was presented by the Methodist Hospitals Heart Failure Interdisciplinary team. The purpose of this meeting was to engage HF patients and their care givers in successful HF self-management skills. Topics on this agenda focused on using evidence-based strategies to enhance quality of life and reduce unnecessary hospital readmissions. Presentation topics included: "Mind your Meds," "Please DON'T Pass the Salt," "Navigation: Care Coordination and Transitions," and "Benefits of a Heart Failure Clinic and a Cardiology Office." A resource fair and heart health screenings were also offered during the program. Participants stated that they felt empowered to take a more active role in their care.

This article was authored by Constance A. Adams, MS, RN, CCNS, CCRN, clinical quality director for the Heart & Vascular Institute at Methodist Hospitals, Inc. in Gary, Indiana.