The Heart Failure Care Management (HFCM) Program at Santa Clara Valley Medical Center (SCVMC) was established in 2012, greatly expanded under a grant agreement between the Valley Medical Center (VMC) Foundation, SCVMC, and the Gordon and Betty Moore Foundation. In its infancy, the HFCM Program consisted of outpatient health education classes. In accordance with clinical guidelines, we further developed the program utilizing a multidisciplinary approach with a goal of improving transition of care, reducing readmissions for heart failure (HF) patients, and optimizing chronic care management through an outpatient clinic.
The HFCM team consists of a cardiologist who serves as the medical director, a pharmacist care manager, a nurse practitioner care manager, and a health education specialist (HES). Both care managers are responsible for duties related to chronic disease management with a focus on optimizing HF guideline directed medical therapy (GDMT). New patients are also enrolled in a two-series HF educational course led by the HES, where they are instructed on self-management skills related to symptom management, medications, diet, and activities.
The primary goals of the HFCM Program are to evaluate, intervene, monitor, and stabilize the patient’s condition to prevent readmission to the hospital and improve symptoms, heart function, and quality of life. We work closely with the General Cardiology team, the Primary Care division, and other important providers in our integrated health system to ensure optimal continuity of care.