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J Am Acad Nurse Pract. 2010 Aug;22(8):417-23. doi: 10.1111/j.1745-7599.2010.00529.x.

An innovative approach to standardizing heart failure care: the heart failure support team.

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Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.



The purpose of this project was to determine if a comprehensive program of heart failure support using a three-step approach during acute care led by an advanced practice nurse (APN) improves outcomes. The goal was to implement Centers for Medicare and Medicaid Services (CMS) appropriate care recommendations for all patients with heart failure, reducing variation, and increasing quality of care.


Retrospective hospital chart reviews demonstrated patients were being admitted with one diagnosis, but ultimately discharged under the heart failure diagnosis-related group (DRG). Because these patients had not been identified as heart failure patients during hospitalization, we discovered an opportunity to improve care through program development.


Once this approach was implemented consistently and sustained, we achieved near-perfect CMS scores. Composite quality scores for patients with heart failure improved from 82.12% to 100%. Electronic tracking of patients after referrals from multiple sources became the keystone of the program, facilitating early identification, teaching, and ongoing patient monitoring.


A comprehensive approach to heart failure support using a team is recommended. However, research is needed to determine if this approach improves quality of life, hospital readmission rates, or lengths of stay for this vulnerable population.

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