“I go to sleep with heart failure every night and I wake up with heart failure every morning.” This quip from a 58 year old man during a support group offers insight into the world of those afflicted with heart failure. Understanding his circumstances gives new meaning to the word, “chronic” and redefines the phrase, “continuum of care.”
Continuum of care for heart failure means that wherever this man goes to sleep and awakens, his heart failure care needs must be met for him to live his life to the fullest. For an individual, a care plan can be constructed based upon the severity of illness and personal circumstances. The continuum of care for an individual changes with their circumstances and progression of illness. Nonetheless, those with heart failure can live highly meaningful lives.
Populations of patients are a totally different story. A population contains every conceivable expression of heart failure in our communities. Some are small children. Others are teenagers after a bout with a viral illness. Many are in the older age group post heart attack or just aging. Defining continuum of care in terms of the population being served can be overwhelming. How can we be all things to all people? The simple answer is we need a plan. A well thought out and carefully executed plan. At first it does not need to be perfect. As we learn, we get better. We seek out science and the peer-reviewed literature. But we find that it is also okay to act on a hunch â such as using the PDSA cycle.
The Colloquiumâs Continuum of Care Approach focuses upon understanding the population served â and finding the âBâsâ before they have symptoms. Staging* is so important that Heart Failure Progression and Accountable Care is a required milestone for accreditation. Proactively searching for the âBâsâ prevents and postpones symptom development and offers the best chance to minimize mortality from heart failure. Of course, other stages and functional classes are all covered too. The Colloquiumâs Domains of Heart Failure Model aptly provides various milestones each interlinked with the others to form our integrated Continuum of Care Approach.
*The American Heart Association Heart Failure Staging paradigm designate Stage B as at high risk but without symptoms.