Transitions of Care: Heart Failure Part 2

presented by Cathy Wollman, DNP, RN, GNP-BC, CRNP

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Financial: Cathy Wollman receives compensation from MedBridge for this course. There is no financial interest beyond the production of this course.

Non-Financial: Cathy Wollman has no competing non-financial interests or relationships with regard to the content presented in this course.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

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This course features an interactive case study. For the best experience, please watch this course on a desktop or laptop computer.

This course will continue to highlight nursing interventions to improve outcomes for SNF residents with heart failure (HF) with a focus on self-care education, discharge planning, and quality transitions of care. Educational interventions will focus on individual resident and caregiver ability to provide self-care and prevent unnecessary hospitalization following discharge. The course will also focus on unique resident goals for HF management, including preferences for end-of-life care. The quality discharge plan will include sharing of clinical data at the time of transition from the SNF. The course will conclude with Part II of the case study of a complex resident with heart failure. This course will assist the SNF to advance their reputation in the community and overall performance scores by providing quality care to residents with HF.

Meet Your Instructor

Cathy Wollman, DNP, RN, GNP-BC, CRNP

Dr. Wollman has been an educator and clinician for more than 35 years. She has worked as a gerontologic nurse practitioner at multiple sites of care across the health care system. She also served as director of senior health for a large health system and the coordinator of the nurse practitioner program for more than…

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Download the learning objectives for Transitions of Care: Heart Failure Part 2.

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1. Education for Self-Care Management of HF Residents

This chapter will focus on the role of the nursing staff and other members of the interdisciplinary team to enable residents and/or their caregivers to manage self-care when they return home. Education needs to be provided with consideration of functional deficits, other chronic diseases, possible cognitive changes, and health literacy. Education will include content related to diet, activity, medications, and signs and symptoms that suggest worsening of chronic disease.

2. Discharge Planning for HF Residents

This course will include essential discharge planning to enable the resident and/or their caregivers to safely manage their care at home. Content will highlight nursing’s role in coordination of care with the interprofessional team and validation that all referrals are in place at the time of discharge. Additional content will focus on the essential clinical data to be shared with follow-up providers at the time of transition from the SNF.

3. Case Study Part 2

Part 2 of this case study will summarize and synthesize the learning acquired in the second course on nursing care for high-risk residents with HF. Interactive technology will allow the learner to use their knowledge and skills to achieve the desired outcomes for a complex resident with HF.

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