During the first 30 days following discharge, heart failure patients face a critical time in their recovery. Close monitoring and support, as well as education about their health process, is key to the best outcome.
Michigan Medicine has developed a program to provide heart failure patients with all the resources they need for success and to minimize the chance for readmission.
The program includes:
- Optimization of heart failure medications
- An engaging education program
- Close monitoring following discharge
- Support from a team including specialists from pharmacy, social work, and nutrition
Patients admitted to the Inpatient Heart Failure Service will be cared for by Michigan Medicine hospitalists on the Michigan Hospitalists Chelsea (MHC) Service. All patients in the program will receive care from the Michigan Medicine Advanced Heart Failure Program through virtual consultation with the hospitalist team. For the first few weeks following discharge, all patients will receive care through the new Michigan Medicine Heart Failure Bridges and Transitions (BAT) program.
What to Expect
The Inpatient Heart Failure Service and Bridges and Transitions (BAT) program will provide patients with the following:
- Collaborative care between the on-site Michigan Medicine hospitalist team at St. Joseph Mercy Chelsea and heart failure specialists at the Frankel Cardiovascular Center through daily, virtual consultations
- Multidisciplinary, protocol-driven assessments and optimization of diuretic therapy
- Pharmacist-guided, protocol-driven optimization of heart failure medical therapy
- Daily virtual consultation from a Michigan Medicine heart failure specialist
- Daily heart failure education from nutritionists, pharmacists, and heart failure specialists using an innovative, interactive virtual curriculum
- Digital self-care monitoring kits to send data to Michigan Medicine providers post-discharge
- Two post-discharge visits within 7 days of discharge with the Advanced Heart Failure Team
- Two post-discharge visits within 4 weeks of discharge with a Michigan Medicine pharmacist
- Establish care with a Michigan Medicine cardiologist within one month of discharge
How to Participate in the Chelsea Inpatient Heart Failure Service
Patients eligible for this program must meet certain criteria to be admitted to the program. Please discuss with your doctor whether this program is right for you.
At the completion of this program, patients will be scheduled to meet with their general cardiology or heart failure provider 3-4 weeks following discharge to continue their care. Through optimal medical therapy, patient empowerment, and close monitoring post-discharge, this program intends to put patients on track for long-term success.