Running head: an interdisciplinary approach

An Interdisciplinary Approach to Congestive Heart Failure
Stephanie Gray, Jessica Keith, Karen Rowland, Jorge Sanchez, Tracy Sansossio,
Dana Taylor and Lori Wells
Distance Learning-Online

Submitted in partial fulfillment of the requirements in the course
Nursing 464: Developing Case Management Skills in the School of Nursing
Old Dominion University
NORFOLK, VIRGINIA
Summer, 2007
An Interdisciplinary Approach to Congestive Heart Failure
Congestive heart failure is “an extremely common illness, accounting for increasing hospital admissions and a large segment of costs to health care systems. It is the leading cause of hospital admissions and readmissions in Americans aged over 65 years of age. The illness has been estimated to account for 2% of total health care costs in industrialized nations” (Goble, A.J., Worchester, M., Le Grande M., & Parkinson, A., 2002). The American Heart Association published the following statement, “advances in the treatment of heart failure and early intervention to prevent decompensation may delay disease progression and improve survival” (Grady, K., Dracup, K., Kennedy, G., Moser, D., Piano, M., Stevenson, L., & Young, J., 2000, pg. number for quote).
Research literature is abundant on the subject of congestive heart failure, although, the literature is not as abundant on the subject of using the multidisciplinary action plan (MAP) with this disease in the hospital setting. The first research article by Ducharme, Doyon, White, Rouleau, and Brophy (date), found discussespresented the impact of care at a multidisciplinary congestive heart failure clinic. This study revealed that care at a multidisciplinary level reduced the number of hospital readmissions and hospital days and improved quality of life. For example, within the MAP one-on-one patient education started with the first clinic visit and ended with a follow up plan. The second study by Goble, Worchester, LeGrande, and Parkinson (date), researched what core features should be included in a MAP. These included patient education, literature with explanation, record of diagnosis and medications to show the patient, discharge plan, home visit and contacts. These features showed extensive improvement in the management of congestive heart failure. For example, hospital readmissions were reduced in all of the 10 studies and the range of reduction of hospital readmissions was from 27% to 73% (Goble, A.J., Worcester, M., Le Grande, M., & Parkinson, A., 2002).
Understanding a MAP
The use of Clinical Pathways or MAP is considered standards for a patient’s care. Quality care is expected for all patients and needs to be delivered in a cost effective and efficient manner. Healthcare is considered very costly and the companies that are expected to pay for the care demand regulations in patient care. The development and implementation of the MAP requires a team to compile the usual aspects of care for a specific diagnosis. The team must include members from all areas of patient care contributing their skills and input for developing this MAP. The timeline of the MAP should include goals to strive for during the patient’s care. The inpatient plan of care should reflect achievable goals for a specific day of care. Although this is a planned timeline, all patients are individuals and may require continued assessment to monitor their personal progress. The MAP requires the collaboration of members from different avenues of inpatient care. The joint efforts and support of all members from clerical to clinical is required to make this plan work to the patient’s advantage. The patient’s outcomes need to be in specific, measurable realistic, and achievable and time referenced. The results of interventions will allow for adjustments in the plan of care.
Benefits of a MAP
The case management plan can be adapted for use by patients and families. Existing MAPs can be rewritten in