Chelsea Heart Failure Program

About the Program

This program requires a referral.

Patients: Please discuss your elibility for this program with your provider. See the "For Patients" section below for more information about the program.

Providers: Select the button below to access the eligibility criteria for the program and a guide for placing referrals.

Blue rectangle with white and yellow text reading "Learn more about patient eligibility information"

The Chelsea Heart Failure Program is designed for patients with heart failure requiring hospitalization. It is a program designed and directed by Michigan Medicine heart failure specialists in collaboration with Michigan Medicine hospitalists. The program begins with inpatient care delivered by Michigan Medicine physicians at St. Joseph Mercy Chelsea Hospital.

At discharge, patients are enrolled in the Michigan Medicine Heart Failure Bridges and Transitions Program. This program provides patients with close monitoring and education during the first month after discharge. This is a critical time as medication changes often need to be made to keep patients well. With several interventions, this program seeks to minimize the risk of repeat hospitalization and set patients on the path to long-term success.

For Patients

About Your Care at the Chelsea Heart Failure Program

The majority of Michigan Medicine patients with heart failure are eligible for this program. We encourage patients to discuss their eligibility for this program with their providers.

Inpatient Medical Care: Inpatient care is provided by Michigan Medicine hospitalists from the Michigan Hospitalists at Chelsea Service.

Inpatient and Outpatient Heart Failure Specialty Care: Inpatient care is guided by virtual consultations with a Michigan Medicine heart failure specialist. Outpatient care is provided by Michigan Medicine Heart Failure Bridges and Transitions Program. This includes both virtual and in-person visits with advanced practice providers and physicians from the Michigan Medicine Heart Failure Program as well as 24/7 telemanagement support from nursing staff trained in monitoring patient symptoms and progress after discharge.

Outpatient visits with Michigan Medicine Heart Failure specialists, pharmacists, and nutritionists are scheduled prior to discharge from Chelsea Hospital. All patients will be provided with a full list of appointments. All post-discharge visits are scheduled to last no longer than one hour. A sample post-discharge visit schedule is included below in the Patient Resources section

Nutritionists: All patients receive inpatient consultation from a Chelsea Hospital nutritionist. In addition, all patients are scheduled to see a Michigan Medicine nutritionist virtually following discharge. These visits reinforce the importance of sodium restriction and fluid restriction to avoid the fluid retention that leads to symptoms of heart failure. Patients are also provided the opportunity to take additional nutrition classes.

Pharmacists: All patients receive inpatient consultation from a Chelsea Hospital pharmacist. In addition, all patients are scheduled to have 1-2 virtual visits with a Michigan Medicine pharmacist after discharge. These inpatient and outpatient consultations focus on educating patients about heart failure medications, screening for side effects, and eliminating medications that may not be safe in heart failure.

In addition to the above team members, this program utilizes physical therapists, occupational therapists, social workers, home nurses, and others to provide the best care possible to heart failure patients.

What to Expect the First Month After Discharge

  • Day 1: Nurse monitoring through Michigan Medicine Heart Failure Program begins
  • Day 3: Virtual Visit with Michigan Medicine Heart Failure team
  • Day 7: Virtual Visit with Michigan Medicine cardiovascular nutritionist
  • Day 10: In-Person Visit with Michigan Medicine Heart Failure team
  • Day 14: Virtual Visit with Michigan Medicine pharmacist
  • Day 24: In-Person Visit with Michigan Medicine cardiologist or HF specialist
  • Day 28: Virtual Visit with Michigan Medicine pharmacist
  • Day 30: Patient assessed for need of continued nurse monitoring by HF team

Services

The inpatient care at Chelsea Hospital and outpatient care through the Michigan Medicine Bridges and Transitions Program will provide patients with the following:

Care & Consultations

  • Highly-rated inpatient care from Michigan Medicine hospitalists and Chelsea staff
  • Daily virtual consultations from a Michigan Medicine heart failure specialist
  • Multidisciplinary, protocol-driven assessments and optimization of diuretic therapy
  • Pharmacist-guided, protocol-driven optimization of heart failure medications
  • Continued long-term care following discharge with a Michigan Medicine cardiologist

Education

  • Education from physicians, pharmacists, and nutritionists using a virtual platform
  • Access to written education materials from Michigan Medicine Heart Failure
  • Access to digital self-care monitoring kits for care following discharge
  • Access to additional virtual nutrition courses at Michigan Medicine

In-Person & Virtual Visits

  • Two visits within 10 days of discharge with Michigan Medicine Heart Failure
  • Two virtual visits within 4 weeks of discharge with a Michigan Medicine pharmacist
  • One virtual visit within 2 weeks of discharge with a Michigan Medicine nutritionist

Patient Resources

 

 

For Providers

Eligibility Criteria

Select the button below to access the eligibility criteria for the program and a guide for placing referrals.

Blue rectangle with white and yellow text reading "Learn more about patient eligibility information"

Patient Information Flyer, Referral Guide and Triage Service Documents

Hospitalist Orientation Materials

Videos from Chelsea Heart Failure Providers