The transition cardiac care manager is a new position at the hospital that will focus on helping CFH patients be successful as they begin making the lifestyle changes needed to keep their disease under control. And hopefully, that will prevent them from returning to the hospital.

“This has huge potential especially because heart failure is a diagnosis where lifestyle makes a tremendous difference in how well a patient recovers,” says Joe Mitchell, RN. “A lot of times patients don’t realize how much better they’ll feel if they follow the recommendations day to day.”

CHF is a chronic condition where the heart does not pump blood as well as it should. Symptoms include shortness of breath, fatigue, swollen legs and rapid heartbeat. It can’t be cured, but a person can live for years with proper treatment and management.

What the Transition Cardiac Care Manager Does

As the new transition cardiac care manager, Joe meets with high-risk CHF patients while they’re still in the hospital to start the education process. He then makes at least one follow-up visit to patients’ residences to ensure their transition to the new lifestyle is going well. Joe’s position is the first of its kind in the Intermountain system.

In a patient’s home, Joe verifies the right medications are being taken properly or explains the complicated dietary guidelines that need to be followed. He also assists in communicating concerns back to the patient’s primary care physician or other specialist.

“I want to be viewed as their guy on the inside who can help decipher the code of healthcare. I’ll guide them through the transition from the hospital to home and then make sure they’re in touch with the right people who can help them from then on,” says Mitchell, who also works with patients treated at American Fork Hospital.

Amber Kayembe, director of Care Management for Intermountain in Utah County, says Joe works with patients for 30 days after they leave the hospital. He then make sure the person’s primary care physician is able to provide the necessary support moving forward.

“Joe is key to encouraging patients and family caregivers to assume a more active role in their care. By putting this position in place, we’re hoping to reduce re-admissions, reduce cost and increase the patient’s outcomes and satisfaction with life,” says Amber.