Management of the Patient With Congestive Heart Failure Using Outpatient, Home, and Palliative

Congestive heart failure is a chronic, debilitating illness, with increasing prevalence in the elderly. It is one of the most common causes for hospital admission, and associated treatment costs are es-timated at $20.2 billion. Despite improved survival with medical therapy, beneficial effects on quality of life have not been consistently reported. In ad-dition, optimum medical therapy, as recommended by evidence-based guidelines, are not always im-plemented. Counseling and education involving di-etary modifications, activity recommendations, medication management, self-monitoring, progno-sis, coping skills, social support, caregiver stress, and spiritual needs are critical components in the management of heart failure through initial diagno-sis to end of life. Within the last decade, close follow-up for congestive heart failure has been as-sociated with decreased hospitalizations, reduced hospital length of stay, improved functional status, better compliance, lower costs, and improved sur-vival. Research trials have mainly been observa-tional and small, and they have used different in-terventions. Little has been written regarding out-patient management of the patient with advanced congestive heart failure, and none of the current published guidelines addresses recommendations for the New York Heart Association class IV (other than for transplant candidacy). New models of close follow-up for chronic and advanced conges-tive heart failure should be investigated. These models could be implemented in urban and rural settings and be supported by private insurance o