Heart Failure Patients Now Get Personal Help to Prevent Another Hospital Stay

The transition cardiac care manager is a new position at the hospital, which treats an average of four patients per week who would qualify for a home visit. And keeping those patients from returning to the hospital is one of the primary goals of the program.

“This has huge potential especially because heart failure is a diagnosis where lifestyle makes a tremendous difference in how well a patient recovers,” said 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.

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

In a patient’s home, Mitchell may verify the right medications are being taken properly or explain the complicated dietary guidelines that need to be followed. He may also assist 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,” said Mitchell, who will also work with patients treated at American Fork Hospital.

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

“Joe is the first of his kind. He will be key to encouraging patients and family caregiver 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,” said Kayembe.