March 24, 2017

Heart to Heart: A Customized Care Plan for Patients with Cardiac Disease

At LightBridge Hospice & Palliative Care, we feel that good anticipatory planning is key to keeping our patients as comfortable as possible in their own home.  Unfortunately we find many cardiac patients managing the effects of advanced heart disease by continuing to utilize the ER to manage symptoms.  This is usually the last place patients and families want to be when dealing with a life limiting illness.  We also learned that patients are most vulnerable for readmission to the hospital, again the last place most want to be, within the first seven days after their discharge  so we decided to develop a program that addresses the needs of patients dealing with cardiac disease. 

Our Heart to Heart program focuses on managing the patient’s symptoms to reduce crisis situations and keep them from returning to the emergency room or hospital. The ultimate goal is to give these patients peace of mind knowing they have an extra system of support when they’re in need.

Patient to Patient

The Heart to Heart program is customized to meet each individual patient’s needs and goals—so the care plan varies from patient to patient. With each new patient, we complete an assessment to determine their medical history and complete a Previous Emergency Visit Assessment (PEVA) which asks the following questions: 

  • When was the last time you went to the ER?
  • How many times have you gone to the ER or were admitted into the hospital in the past six months?
  • In the past year?
  • When you got to the ER, what did they do for you? What brought you comfort?

We then develop a care plan that mirrors the interventions that brought the most comfort and relief.  This plan will include providing all the necessary medications, equipment, and supplies needed to manage any anticipated cardiac issues at home.

Heart to Heart

Because The Heart to Heart program’s main goal is effectively managing the symptoms and discomfort of our cardiac patients and prevent their need to return to the hospital or ER, we focus on controlling the disease to minimize the risk of another exacerbation of their disease.

It is really a three-part plan: we teach our patients about compliance, carefully monitor them to detect any early stage of fluid overload, and then implement specific comfort care measures as necessary.

The biggest—and often most challenging—part of controlling the symptoms of cardiac disease is compliance. For cardiac patients it is very important to maintain a low sodium diet, which is very difficult to do as many favorite foods and drinks have high sodium content.  When we are working with patients in their advanced, life-limiting stages of the disease we want to balance the need to be compliant with the patients’ desire to live their remaining time without constraint.  It is important for us to explore what the patients’ health care goals might be.  Is it being well enough to walk their daughter down the aisle in a couple of months or perhaps its being able to hold their first grandchild?  Knowing their goals allows us to guide and educate around compliance while still living each day to the fullest and as freely as desired.  

Because of this approach we carefully monitor the patient for early signs of fluid retention and take steps to ensure any symptoms are managed before becoming problematic. 

Finally, Heart to Heart aims to provide our patients and their loved ones with 24/7 support. They know they can call us if they have any questions; or, if they feel additional visits are necessary, we’ll go out and check on them. We realized early on that reassurance is such a key part of what we do so we make it a priority for our families to know we’re going to be there for them. 

If an emergency does happen, we already have the comfort measures set up in the patient’s home. Once families understand we are often capable of implementing the same cardiac care that the ER would, they are more reassured and happy to avoid that trip to the hospital or ER. Because we have the program in place and are monitoring the patient, we actually rarely have to implement our emergency care plan.

You can count on LightBridge to customize a care plan to give you and your loved one peace of mind when it comes to managing their cardiac symptoms. Visit us online or call (858) 458-2992 to learn more about how our Heart to Heart program can give you an extra layer of support.

By: Cindy Hutchinson, RN, Vice President, Clinical Operations