Tag-teaming Heart Failure

Continuous care for chronic diseases

team of doctors in a circle all hands in

Living with heart failure can be tough. It can’t be cured. But it can be controlled, improving your quality of life.

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You don’t have to go it alone. If your primary doctor is part of patient-centered medical home practice, help and advice in controlling chronic diseases like CHF are much easier. Your primary care doctor, cardiologist, nursing staff and other caregivers give you the tools you need to monitor your condition and keep you healthier.

Internal medicine physician Muhammad Syed, MD, says, “Access is all important. We keep patients in the loop and on the radar. They feel like they’re being looked after.”

It’s goal-oriented, team-based healthcare, with you the most important team member.

About heart failure

The term “heart failure” doesn’t mean the heart has stopped working. It means the lower chamber of the heart isn’t pumping with enough force, or the heart’s ventricles don’t relax and fill the way they should. Heart failure affects nearly 6 million Americans.

Depending on the severity of your heart failure there may be no symptoms, or they may include:

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  •  Shortness of breath or difficulty breathing and dry, hacking cough
  • Swollen ankles, legs, abdomen
  • Rapid water weight gain, if you gain more than or equal to 4 pounds in a matter of days
  • Dizziness, fatigue and weakness
  • Rapid or irregular heartbeats

How a team-based healthcare model helps

Say you’ve had an attack, it’s impossible to catch your breath and you’ve been taken to an emergency room for treatment. If your physician is part of a patient-centered medical home, nurses will be in contact with you as soon as you’re discharged from the emergency department.

Depending on the severity of your problem, they will:

  •  Monitor you as closely as necessary so you don’t end up back in the ER
  • Follow up to help you with your blood pressure, diabetes or whatever caused you to go into heart failure
  • Ensure you are taking your medications without problems

Taking charge of your condition

To nip any potential problem in the bud, you’ll be taught how to keep a close eye on your health and what to do to reduce flares. You’ll be prescribed medications, advised to weigh yourself daily, taught to use a blood pressure monitor and given a healthier diet to follow.

Your team will be there to provide support and help you problem-solve issues that get in the way of your health.

If your blood pressure reading is high (greater than 140/90), let the team know. If you gain even as little as a pound or two, it could be a problem and you should notify your doctor. If you’re experiencing shortness of breath, make a call.

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As the key member of your healthcare team, it’s up to you to take the lead on your care, says Dr. Syed.

“It’s a behavioral thing,” he says. “It takes time for some people. But once they see the benefit, they buy in.”

Cleveland Clinic’s Medicine Institute was officially recognized as a patient-centered medical home in 2010. Medical homes exist at the Family Health Centers and on Cleveland Clinic Main Campus. Different models of team-based care are at three of Cleveland Clinic’s primary care locations: Strongsville, Independence and Cleveland Clinic main campus Internal Medicine Department.

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