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Coordinating Care for Patients With Chronic HF
Î Effective systems of care coordination with special attention to care
transitions should be deployed for every patient with chronic HF that
facilitate and ensure effective care that is designed to achieve GDMT
and prevent hospitalization. (I-B)
Î Every patient with HF should have a clear, detailed, and evidence-
based plan of care that ensures the achievement of GDMT goals,
effective management of comorbid conditions, timely follow-up with
the healthcare team, appropriate dietary and physical activities, and
compliance with secondary prevention guidelines for cardiovascular
disease. This plan of care should be updated regularly and made readily
available to all members of each patient's healthcare team. (I-C)
Î Palliative and supportive care is effective for patients with
symptomatic advanced HF to improve quality of life. (I-B)
Quality Metrics/Performance Measures
Î Performance measures based on professionally developed clinical
practice guidelines should be used with the goal of improving quality
of care for HF. (I-B)
Î Participation in quality improvement programs and patient registries
based on nationally endorsed, clinical practice guideline–based
quality and performance measures can be beneficial in improving
quality of HF care. (IIa-B)
Table 36. Outcome Measures for HF
Measure Developer
Congestive HF mortality rate
(NQF endorsed)
Agency for Health Research and Quality
HF 30-d mortality rate
(NQF endorsed)
Centers for Medicare and Medicaid Services
Congestive HF admission rate
(NQF endorsed)
Agency for Health Research and Quality
HF 30-d risk-standardized HF
readmission rate (NQF endorsed)
Centers for Medicare and Medicaid Services
