For the nearly 6 million people in the United States living with congestive heart failure (CHF), a relentless schedule of appointments with specialists, medication management, and even hospitalizations may seem inevitable.
But Samaritan’s CHF Disease Management Program provides South Jersey heart failure patients with a continuum of services that deliver compassionate clinical care through every stage of the disease, which can often last for years. The program helps patients manage heart failure in primary care, palliative care, and hospice care to address end-stage CHF.
“Very often in our health care systems we see ‘silos’ of care – different physicians treating different issues, and often telling patients different information,” says Stephen Goldfine, MD, DABFP, CAQGM, DABHP, Chief Medical Officer at Samaritan. But that’s not the case with the continuum of care provided by Samaritan’s CHF Disease Management Program.
“We have multiple levels of care – home visit physicians, our palliative care program and our hospice program,” Dr. Goldfine explains. “So you can come to us at any stage in your disease, even much earlier than you might expect, and we can help you.”
At the simplest level, heart failure is any time the heart is not functioning as well as it should, says Dr. Goldfine.
“The heart itself doesn’t pump blood to the body effectively,” he says. “So less blood is going to your lungs and your other tissues, and you become somewhat weak.”
The symptoms of CHF are wide-ranging, and some may be more obvious than others, says Sara Pagliaro, DO, Vice President of Medical Services at Samaritan.
“Some major things you might see are trouble breathing as you’re doing normal activities, such as walking to the mailbox or walking your dog,” she explains. “You might find that your legs are swelling, or your belly seems like it’s more swollen and your clothes aren’t fitting well.” Other symptoms could include weight gain, cough, loss of appetite, difficulty breathing when lying down or trying to sleep, and increased heart rate or palpitations.
As any patient with CHF and their family knows, managing the medications and different specialists required by the disease can be a challenge – and that’s why care coordination can be so important, and helpful.
“We want you to have a team approach to your heart failure management,” Dr. Pagliaro says. “Care coordination is so important, especially with Congestive Heart Failure. We want our patients to feel like they have a group of people they can call who are communicating with each other about the best care, and that we’ve set goals about your care based on what you want for your quality of life moving forward.”
Care coordination for CHF starts with primary care, which is provided by Samaritan’s HomeVisit Physicians. Samaritan’s CHF care at home acts as the “quarterback” of the continuum of care, with physicians, nurse practitioners, and physician’s assistants providing comprehensive evaluations for patients in the comfort of their own home. Samaritan clinical providers work with other specialists, such as a cardiologist, to form a treatment plan that helps manage heart failure in primary care in the best way possible.
The benefits of CHF care at home can be enormous – Samaritan’s HomeVisit Physicians see patients at their best and at their worst. For patients who may be temporarily or permanently homebound, it provides an opportunity to meet with a clinical provider in person. Centers for Medicare and Medicaid Services data from clinical outcomes has shown that frequent visits, especially after a patient leaves the emergency room or hospital, have reduced ER visits and readmissions to the hospital within a 30-day period.
If patients suffer pain, Samaritan’s palliative care for heart failure may be able to help. But Dr. Pagliaro says that palliative care is often misunderstood.
“Often, patients hear the term palliative care, and they expect that they will not be able to continue with their regular medical team, or they may not be able to leave their home or enjoy the things that they once did,” she says. “But palliative care is very much life-enhancing. It’s improving a patient’s quality of life and functional status, as much as their body is able to handle.”
Samaritan’s palliative care for heart failure is about optimizing quality of life – providers help address the pain, symptoms, and stresses of serious illnesses like CHF. They also facilitate conversations between patients, their families, and their clinical care teams to better understand the quality of life the patient is seeking, and develop a care plan to sustain that.
Samaritan’s Advanced Cardiac Care Program is another innovative force in palliative care for patients with CHF, allowing patients to continue their current medical intervention as Samaritan providers manage their heart failure symptoms and medications strategically, ensuring patients have the best quality of life.
“We’ve partnered with the American Heart Association and the National Partnership for Healthcare and Hospice Innovation to create a comprehensive program that takes care of patients with heart disease and heart failure, to make sure they get the best care possible,” says Dr. Goldfine.
When CHF progresses to its final stages, patients typically face symptoms that are more severe. End-stage CHF patients may experience the following symptoms:
At this point, the hospice portion of Samaritan’s CHF Disease Management Program may be able to help.
To be clear, says Dr. Goldfine, hospice care does not mean giving up. “In the past, it was thought that hospice would just give patients morphine and make them sedated. That’s not the case with Samaritan,” he says. “Samaritan looks at those patients and we manage their medications aggressively.” The goal, he says, is to focus on a patient’s level of comfort, and keep them out of the hospital as much as possible, so they can be at home to enjoy time with their family.
Hospice care helps patients and their families address the complex issues of end-stage CHF – including the medical, emotional, psychological, social, and spiritual needs the disease presents. The Samaritan care team of physicians, registered nurses, home health aides, social workers, spiritual support counselors, and massage or music therapists work together to provide end-stage CHF care at home to patients. This may include everything from helping a patient manage pain through medication, to helping with bathing and grooming, to guiding the patient and their family as they cope with grief and end-of-life issues.
“Our care coordinators really focus on quality of life for every patient, and ensure that they are receiving the right level care at the right time,” Dr. Goldfine says. “You can come to us at any stage in your disease and we can help you.”