Paper Example on Congestive Heart Failure: A Growing Epidemic

Introduction

Currently, congestive heart failure (CHF) is one of the emerging epidemics. An epidemic is an outbreak and as such, it affected many people and can spread rapidly because of increased incidence. Congestive heart failure refers to the clinical syndrome caused by structural or functional cardiac disorders and can cause the ventricle's ability to eject blood. As a public health problem, it is important to carefully examine the history as well as physically examine the clinical condition before making a diagnosis. The health needs of these people include support to overcome personality disorder, suicide risk, cognitive impairment, current or past psychosis, active alcohol/substance abuse or dependency and current or past bi-polar. The health needs can only be addressed through multidisciplinary intervention across the continuum of care from the day the patient is admitted into a hospital to the day they are discharged to a skilled nursing facility up to the time they go back home for home-based care under the supervision of the case manager.

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Services and Interventions Addressing the Health Needs of the CHF Patients

Identify care partners

Based on the fragipan criteria, congestive heart failure can either be major congestive heart failure, or minor CHF. Case managers must, therefore, collaborate with other care providers, assess, plan, facilitate and coordinate care then evaluate the outcome and advocacy options and services to satisfy the CHF patients health need. Many CHF patients are admitted to hospitals each year. However, a higher percentage are readmitted to the hospitals due to the same conditions (Case Management Society of America, 2016). Being elderly, the patient risks neglect or premature death. Through education, the Case manager can help prevent such incidences and prevalence. Vetting home health agencies can pick partners aiming to provide the best care for the best patient outcomes. According to Moore, Jiang, Manson, Beals, Henderson, and Pratte (2014), the home heartcare providers track the patients' health and provide telehealth progress in the country, this way, it was easy to keep in contact with the patient and the hospital that we serviced care. All patient sent to skilled nursing facilities (SNF) from the hospital also benefit ed from the continuum of care as the partners continued to prover care even after the patient had been moved from the SNF to their homes to continue with home healthcare. After identifying the organization that has CHF programs, the educational materials are used to provide consistent and constant education to the CHF care providers.

Liaising and Collaborating with All the Partners

The second step is to get all the crew providers on board with the congestive heart failure exciton. The case manager will assist in terms of collaboration and care continuity. All the care partners case managers will be required to liaise to deliver consistent patient education around CHF. The partners can easily collaborate because the three partners did not have any financial interest in the business of other partners as they were guided by one goal to produce the best patient outcome (Case Management Society of America, 2016). It is only through case management that the hospital, home health, and the SNF can have consistent educational strategies and outcomes. Because of the accountable care organization's objective, it is easy to break down silos and improve patient care for better put comes

Health Promotion

The third step for a case manager is to select and implement the best practices for CHF management. The programs will provide the patient with a manual stating then educational information about their health and medical condition when to call a doctor or when to contact the home health agency. The manual will also have blank spaces for the patient or relatives to record all the vital signs. Apart from treating the patient, they will also be taught how to take care of themselves

Coordinating with the staff at discharge is an important part of the case managers duty. When the patient is being discharged from the SNF, the case managers call the home health and make all the arrangement for the patient and advocate for the patient. This way, the patient and their family can meet the home health nurse to get to know each other because some patient can not allow unauthorized personnel to attends to them. the post-acute transitional care managers are employees of the HCO organizations who are sent to work in the SNF facilities where the HCO has a prefeed provider relationship. It is the duty of the transitional care manager to collaborate with the SNF and the case management team also attend case reviews then liaise with the case managers in the SNF (Moore et al., 2014). The case managers will be the on overseeing patient care till the time of transitional team takes over and the follow-up can run up to one month.

Cost-Effective Interventions Promoting Health and Preventing Illness

Collaborating and Navigating Past Problems

Collaboration should be seamless among the providers of care, financiers and nursing facilities. Therefore, from the time the patient is admitted, the healthcare providers should ensure that all the care partners are on the same page and the patient is educated about the medical condition. The patient should be monitored closely from the time they enter the hospital to the time they are discharged and given post-discharge care.

Work with Patients and Their Families to Prevent Readmission

Those patients who have had minor CHF crises are likely to be taken to the ED without the home health agency being notified. There are cases that can be handled at home but the fact that there are no data to support these home-based intervention makes them overlooked (Moore et al., 2014). Therefore, the patient or their family members should content the home health agency that provides home-based cares before sending them to the emergency department. Some of these health issues can easily be addressed by the home health agency or the SNF. The more the care providers partners communicate, the better the patient outcomes.

Intervention

The intervention implemented by the grantees consisted of individual case management, disease management, and self-management education. Participants received a baseline medical evaluation of CVD risk. An assigned nurse, pharmacist, registered dietitian, or behavioral health-social services (the latter with clinical backup) case manager saw patients monthly (initially) and then quarterly (once stabilized). The case manager developed an individualized care plan for CVD risk reduction for each participant and periodically updated it in response to participant progress.

Treating CHF risk factors to the target goal. Each patient should have individualized treatment goals and regime depending on their CHF condition. For those whose conditions are worse, angiotensin-converting enzyme inhibitor to open the narrowed blood vessels. Blood flow will be improved. Additional, ACE inhibitors intolerant patient can be given vasodilators. High blood pressure should be addressed in addition to lipid disorders. Beta blockers can also be prescribed. Nonpharmacological intervention is also advised in addition to health promotion.

Risk Management

The first goal of a case manager in determining the risk factors of the patient. In this case, the patient is already elderly which is a major risk factor because the patent is over 65 years of age. Case management programs busily target the health improvement for the patient with CHF and in most cases can significantly reduce readmission rate by 50% (Clark, 2019). Case management requires collaboration between the care pastness such as the innovative care partners, the life care partners of America as we as assisted home health and hospices. Cael management requires more than three organizations to work together to ensures that the patent receives consistent CHF health education and care. CHF high care quality that is why case management is the most effective strategy.

PHM is mainly driven by business intelligence that relies on data analytics BI and data analytics help PHM in archiving the goals by analyzing cross-sectional and longitudinal data to determine the most cost-effective intervention. In PHM clinical data financial data and operational data from different parts of the organization are integrated to develop actionable steps for all the care providers. In the recent past, predictive analytics is the most commonly used form of analyze. The most important part of population health management is the real-time insight into the health condition of the at-risk population. From the analysis, the providers can easily identify any of the care gaps that should be addressed within the patient population. It is through the identification of care gaps that HCO can quickly solve a to improve patient outcomes and reduce the costs of operations.

Conclusion

Population health management should focus more on health promotion as opposed to reactive starvation such as pharmacological intervention. Health portion involves educating the entire population on the various health condition and the risk factors associated with CHF. Therefore, before the patient is discharged, the case manager should liaise with other relevant and available care providers in the continuum of care to educate the patient, family, and population on the CHF. This way, the patient would manage the risk of the condition and the disease itself.

References

Case Management Society of America. (2016). Standards of Practice for Case Management. Ranch Drive Little Rock, AR 72223: CMSA.

Clark, M. (2019). Population and Community Health Nursing (6th ed.). Upper Saddle River, NJ: Pearson.

Moore, K., Jiang, L., Manson, S., Beals, J., Henderson, W., & Pratte, K. et al. (2014). Case Management to Reduce Cardiovascular Disease Risk in American Indians and Alaska Natives with Diabetes: Results from the Special Diabetes Program for Indians Healthy Heart Demonstration Project. American Journal of Public Health, 104(11), e158-e164. Doi: 10.2105/ajph.2014.302108