Heart Failure Program

ALL HEART

Introducing St. Tammany Health System's Transitions of Care Congestive Heart Failure Program



Congestive Heart Failure Program

 

Heart failure is a lifelong condition in which the heart muscle can't pump enough blood to meet the body’s needs for blood and oxygen. Basically, the heart can’t keep up with its workload.


The prevalence and risk for heart failure is increasing with an estimated 6.7 million adults having the condition.


With this ever growing  disease, St Tammany Health system has assembled a team of healthcare professionals  to aid in the coordination, management, and prevention of heart failure (Heart Failure Program).


The Transitions of Care Heart Failure Program at STHS is a home-care-based program  providing specialized  care to patients with heart failure for 90 days after discharge from the hospital.  Assessment, evaluation, management,  prevention,  coordination amongst specialties, and ongoing monitoring are  at the core of the heart failure program with an overall goal of maintaining health  and avoiding risk factors that may lead to hospitalization or poor health outcomes.


More about STHS's Transitions of Care

A closer look at the five facets of our Congestive Heart Failure Program:

 

1. ASSESSMENT AND EVALUATION

  • Assessment with St. Tammany Health System’s Transitions of Care Congestive Heart Failure Program begins while you are an inpatient in the hospital and is continued into the patient’s home with provider and nursing visits.
  • Evaluation of heart failure is an ongoing process that involves listening to heart and lung sounds, calculation of jugular vein distension, vital sign review and measuring of edema/swelling.
  • Includes ongoing and “as needed” assessments.


2. MANAGEMENT

Management of a chronic condition like heart failure is often complicated and requires the use of expert providers, patient participation in monitoring, and the use of technology resources made available through St. Tammany Health System. This may include:

  • Algorithm treatment/diuretic management.
  • Ability to direct your care based on symptoms as well as diagnostic tests that may be ordered.
  • Advanced options for home treatment including IV and subcutaneous diuretic management.
  • Labwork and radiology.
  • Constant coordination via Epic or phone consult with specialty services including Cardiology, Pulmonology, Nephrology, etc. This will ensure your entire healthcare team will be apprised of your management.
  • Remote patient monitoring.

3. PREVENTION

  • Diet and lifestyle.
  • Custom-designed, program-specific refrigerator magnet to guide patients in assessing warning signs and symptoms.
  • Addressing social determinants of health. Registered nurses will perform an assessment and address needs such as housing concerns, meal insecurity and transportation issues. Ensuring you are set up for success through addressing these social determinants can help to prevent heart failure exacerbations.
  • Remote patient monitoring.                                      

4. COORDINATION OF CARE

  • One of the main roles of your heart failure program team is to effectively communicate your treatment plan to you and coordinate with all providers participating in your treatment plan.
  • Utilization of Epic to share notes and update providers involved in your care.
  • Remote monitoring shared to providers involved in your care.
  • Our STHS heart failure program has fostered relationships with all home health agencies in the area to ensure communication of assessment findings or any concerns identified in a home health visit.
  • Coordination of Cardiac Rehab referral, if warranted.
  • Palliative Care referral for those patients needing additional support and symptom management at the conclusion of the program.

5. ONGOING MONITORING

Ongoing monitoring of heart failure is critical, as this is a lifelong condition in which symptoms are likely to fluctuate. Preventing exacerbations and avoiding worsening of overall cardiovascular health is the long-term goal of the St. Tammany Health System Transitions of Care Congestive Heart Failure program. With the utilization of resources listed below, we have actualized successful heart failure monitoring. Our ongoing monitoring may include:

  • Post-acute navigation contacts.
  • Heart failure program in communication with patient’s home health service with health updates.
  • Providing of materials and medical equipment.
  • Remote monitoring for daily review of vital signs by the Heart Failure Program, with an option for virtual communication through remote monitoring equipment.
  • Get Well Loop: Every discharged patient will receive a text or email for the Get Well Loop service. This is a digital platform to help St. Tammany Health System stay connected to our patients. It is a patient care and education tool that allows St. Tammany Health System care providers to send helpful instructions, education and reminders to patients. This is a two-way communication through which patients can escalate concerns and questions.
  • Cardiac Rehab.


Program hits home for congestive heart failure patients

Congestive heart failure is a life-changing diagnosis, but a new program from the STHS Home Care team is helping ease the burden for people like Mary Bahn. Hear her tell her story.




Meet the team

The Transitions of Care Heart Failure program at St. Tammany Health System is a home-care-based program made up of trained professionals who provide compassionate, specialized care to patients with heart failure for 90 days after discharge from the hospital.

STHS CHF home care team

More about STHS Transitions of Care

A closer look at our program's full offerings:

 

transitional home care

An overview

Being discharged from the hospital can be stressful for you and your loved ones. Thanks to St. Tammany Health System’s multi-faced Transitional Home Care program, it doesn’t have to be.

traditional post-hospital home care

Post-hospital home care

Traditional transitional care centers on post-hospital home care. It is offered to patients following a hospital stay to ensure a smooth transition from your hospital stay to your regular home life.
copd program

COPD program

The Transitions of Care COPD program at St. Tammany Health System is a home-care-based program providing specialized, post-discharge care to help patients with chronic obstructive pulmonary disorder (COPD) manage their conditions.


We are here.

Whether you’ve got a question to ask or an appointment to keep, getting in touch with us is a cinch. Here’s everything you need to know:

 

STHS Transitional  Home Care

101 Ashland Way, Suite 1
Madisonville, LA 70447

 

Phone: (985) 871-5955 

Fax: (985) 871-5954 

Remote patient monitoring: (985) 871-5978