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The Heart Failure Society of America, in June of 2015, initiated a collaborative multi-organizational effort to identify and establish benchmarks and resources to improve the standards of quality care for those impacted by heart failure. The overall goal is to improve upon the systems of care in order to standardize best practices and ensure continuum of care for HF patients.

The Quality Care taskforce identified the current unmet needs, when they convened all constituencies concerned about heart failure together, which included primary care physicians, hospitalists, emergency physicians, patients, and allied professionals, to discuss current best practices that have shown promising results for curbing heart failure readmissions, and identify areas where gaps in care exist and require necessary improvements.

In today’s healthcare environment, there is a need to develop educational tools, resources, and education opportunities that inform practicing healthcare professionals on the changes in new or updated heart failure treatment. The Quality Care task force is working to develop high quality, un-biased educational activities and resources that are based on the most up to date science and information available. The Quality Care Taskforce Initiative will positively affect patient outcomes, and aid in developing new models of care, educating patients and providers on evidence-based heart failure care standards, and sharing strategies for reducing/preventing readmissions and risk for mortality.

Group Overviews including – Focus Areas, Objectives, Resources Deliverables, and Projected Delivery 

Group 1 Focus Area: Increasing adherence to guideline-directed medication/device therapies/performance measures
  • Established Best Practice Model for Care Transition and Medication Adherence
  • Increased use of guideline recommended devices
  • Increase use of guideline recommended medications
Project Description/Purpose

The goal is establish relationships and process with pharmacies that would allow for continued monitoring of patients to ensure they are following the medication directives in order to bridge the gaps in medication adherence as the patient transitions from the hospital to home and ensure on-going monitoring of medications effectiveness and the need for changes.

Intended Tools & Resources Overview

Group 2 Focus Area: End-of-life/Palliative Care/Stage D Care
  • The intended goals for this group is to provide patients and caregivers with more focus on understanding the different stages of HF, and how to prepare your life through each stage of HF, but also focusing on how to live the best possible live with HF.
  • The intended goal for this group is to aid providers with improving communication with patients and caregivers as they transition through each stage of HF.
Intended Tools & Resources Overview

Patient & Caregiver Module: Living Your Best Life With Advanced Heart Failure

The group has decided to focus on living successfully with HF though all the stages. Although diagnosed with HF it is important the patients enjoy their life despite the chronic disease.

They goal is to focus on what everyone needs to know and develop checklist for life that discusses the following:

  • Finances, Wills, Advanced Directives
  • Focus of understanding treatments and medications through all phases of HF
  • Focus on helping patients find hope
  • Checklist for Life
  • Additional focus areas include staying vibrant and safe. Building strength – Diet, exercise, healthy mind, Living situations, Planning help for the care givers – How to stay independent with HF – Redefine the self-image – Helpful devices, Preventing falls, and safety tips.

Provider Education Module: Best Practices for effective communications with Patients & Caregivers

Ensuring effective communication with patients who have heart failure is a major challenge. The lack of openness that some patients perceive may be related to the difficulties faced by doctors in sharing information about prognosis and the nature and course of the condition that may be vague or misleading.

The goal for this resource is to provide a simplified and consistent messages that aids all heath care providers with improving how and when they are communicating with HF patients to ensure that each patients can live their best possible by life at each stage of the disease.

Resource will be available November 30, 2018

Group 3 Focus Area: Care Coordination/Transitions/Safety
  • Conduct a research study to examine hospital and ambulatory services for heart failure care and determine which services are associated with post-discharge 30-day re-hospitalization.
  • To describe patients’ journeys in living with HF by obtaining responses to questions related to 9 themes: (1) symptoms and influence of symptoms on daily activities and communication with providers; (2) communication; (3) confidence in managing care; (4) shared decision-making; (5) knowledge about HF; (6) psychological support; (7) caregiver support, (8) worsening HF and (9) advanced care planning/palliative care.
  • A secondary purpose is to examine if responses to items in each theme are related to patient demographics and HF characteristics.
Project Description/Purpose

Research Study

In order to better understand the scope of inpatient and outpatient services provided by hospitals/medical centers (and community centers), investigators wish to describe hospital and ambulatory services for HF care and learn which are associated with post-discharge 30-day re-hospitalization. Findings may guide clinicians who are developing or revising team-based care programs aimed at improving clinical care during transition periods.

Anticipated Outcomes and Resources: September 30, 2018

Patients’ Journey with Heart Failure – Transition From Hospital to Home

Since patients are key stakeholders in their health and self-management, it is important to learn more about their perspectives in terms of needs, issues, strengths, and opportunities. It is known that patients who are “activated” toward higher self-management have better clinical outcomes. Activation requires patients to know how to care for themselves and also, what actions to take during difficult times or when uncertain about their health. To learn patient’s perspectives, an investigator-developed, anonymous survey will be used, and best practices will be established based of the outcomes of the results.

Anticipated Outcomes and Resources: December 31, 2018

Group 4 Focus Area: Better HF Diagnosis/Recognition of Worsening HF/ED care/ Starting a HF Clinic Toolkit
  • Establish best practices and a toolkit that will aid HF practitioners with developing their own HF clinics.
  • Develop comparison tools, identify norms, and establish guidelines to both HCP’s and PCP’s to use to analyze their own patient populations.
Project Description

How to Develop a HF Clinic Toolkit

The QCI taskforce convened a working group with the express goal of creating this practical document and accompanying toolkit containing best practices to be utilized when establishing a successful heart failure clinic.  Of note, the scope of this document is limited to resources that would optimally serve those not yet on home inotrope therapy, those with a ventricular assist device (VAD), and those post-orthotropic heart transplant (OHT).  Many of the principles that will be discussed in this guide will be applicable in those settings as well; however, there will not be specific mention of resources needed to care for those niche patient populations.

Anticipated Outcomes and Resources: July 15, 2018

Group 5 Focus Area: Gaps/Disparities/Minority Population Care/Gender Disparities
  • Provide guidance to providers offering clinical preventive care, health promotion, and disease management services on ways to use HF health risk assessment tools followed by evidence-based health improvement programs in underserved populations.
  • Ultimately, reduce health disparities through the use of HF health risk assessment tools and follow-up interventions that are linguistically and culturally tailored and are available to persons with disabilities and other underserved populations.
  • Improve understanding and participation in clinical trials by the underserved populations.
Project Description


Focused Risk Assessment Tools

The purpose of the updated risk assessment tool is assist non-HF providers with better identifying underserved patient populations that may present a risk for HF. The goal is encourage providers to understand their patients’ medical history, family history, and provide insight that HF can impact anyone at any age. Additionally the goal is to provide a tool providers can utilize to communicate with patients so they can better understand their potential risk.

Anticipated Outcomes and Resources: September 1, 2018


Developing a webinar geared toward Non- HF HCP’s that would provide education on discussing clinical trial options with patients, with a focus on those that care for a number of HF patients in underserved communities.

Anticipated Outcomes and Resources: November 30, 2018


Collaborative Organizations & Program Support

The Heart Failure Society of America would like to thank Amgen for their continued support in the ongoing efforts to improve quality care in the Heart Failure community, and for their founder level support of the HFSA Quality Care Initiative.

HFSA would also like to thank St. Jude Medical/Abbott, Bayer, and Novartis for their support of the initiative as well as all of our 17 collaborative stakeholder organizations. It is HFSA’s belief that this is the most collaborative working group on HF quality care in the US.

Collaborative Partners
  • AAHFN – American Association of Heart Failure Nurses
  • Society for Academic Emergency Medicine (AECM)
  • Society of Hospital Medicine (SHM)
  • ACC – American College of Cardiology
  • AHA – American Heart Association
  • Association of Black Cardiologists (ABC)
  • Association of Cardiologists of Indian Origin (AACIO)
  • American College of Clinical Pharmacy (ACCP)
  • ISHLT – International Society of Heart and Lung Transplantation
  • Preventative Cardiology Nurses Association (PNCA)
  • WomenHeart
  • Mended Heart
  • Heart Brothers Foundation
  • AMGA
  • American College of Emergency Physicians
  • American Academy of Hospice and Palliative Medicine
  • National Minority Quality Forum



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