Module B: Assessment & Value-Based Care Coordination

CE Credits: 2.0


Because heart failure patients fare much better if diagnosed and treated as early as possible, this module explores the main risk factors and symptoms than can help healthcare providers make an early diagnosis of heart failure. Then, it details the main diagnostic tests—including echocardiograms, blood tests or cardiac MRIs—used in determining if a patient has HF, as well as the different classes of the disease, to help pinpoint both the disease’s severity and the patient’s functionality. Finally, the module looks at strategies that transdisciplinary team members can use—such as the STAAR initiative—to coordinate care for HF patients and help reduce their chances of rehospitalization.

Learning objectives: After completing this module the case manager will be able to:
» Review the initial medical workup
» Describe key elements of testing and interpretation
» Identify heart failure classification methodologies
» Discuss the role of cost versus value and evidence-based practices
» Describe care coordination and transitions of care
» Discuss strategies for improving care with the “Hospital 2 Home” and “STAAR” quality initiatives.

Advance your professional practice:: Early diagnosis and treatment can help HF patients live longer, more active lives. When case managers understand the early diagnosis and classifications of HF, we can support other team members as we coordinate care for patients.


Improve organizational performance: Heart failure patients have a notoriously high rate of hospital readmission, which is bad for both the patient and for the hospital, since such readmissions often mean lower reimbursements for care. If the members of the transdisciplinary team are more proactive in diagnosing patients—and coordinating effective treatment for them—we can reduce readmission rates and improve patients’ quality of life.