The Transitional Heart Failure clinic (THFC) provides home-based care to frail patients with heart failure who are approaching the end of their life. The main goals of patient care are to control symptoms, maximize function, maintain quality of life and reduce admission to the Emergency Department and to the hospital. This clinic service is provided by a nurse practitioner and a group of physicians from Internal Medicine, Geriatrics & Palliative Care.
How do I get an appointment?
The Transitional Heart Failure Clinic is a specialty service. Patients who are frail and are living with end-stage heart failure must be referred from a Specialist clinician from the Nova Scotia Health Authority. At this time the clinic can provide service to patients who live within 35Km from the QEII Health Sciences Centre. You are not required to have a Family Practitioner in order to be accepted to the THFC service.
How do I prepare for my appointment?
Patients who are referred to the Transitional Heart Failure Clinic will be contacted by the clinic nurse practitioner to schedule their appointments. It is most helpful to have a family member or your next of kin available for at least the first appointment. To prepare for your appointment, please have the following:
- A list of questions and concerns about your heart failure.
- A list of people or services involved in your care
- All the medication that you take available for review
- Record your weight daily before your first and follow-up visits
- Have an advanced directive and/or consider your wishes and goals for your health and discuss these with your substitute decision maker and/or family.
What questions should I ask?
Below are questions that you may want to ask at your first appointment.
- What can I do to manage my health?
- How will the THFC help manage my health?
- What is the role of my family practitioner?
- What is an Advanced Directive?
- What is the Special Patient Program?
- When do I call the THFC nurse practitioner?
- When do I call an ambulance?
What will happen at my appointment?
You will be visited by a Nurse Practitioner (NP) in your home. The NP may also be accompanied by a THFC doctor. The first visit will be a minimum of 2 hours and will involve gathering information and reviewing your current overall health needs, symptoms, supports and goals for your care. The main goal will be to reduce symptoms of heart failure and begin to develop an Advanced Care Plan for you that is in keeping with your goals for care.
At the first visit and at each follow-up visit, the NP will review your questions, concerns, and symptoms of heart failure, medication, record of weight, available supports and Advanced Care Plan. The NP will also take your pulse, blood pressure, listen to your heart and lungs and check for signs of heart failure (i.e. swelling). The NP will adjust medication based on all of this information and help to put supports in place for you and your family in order to address your health needs, improve your symptoms and your quality of life.
Some patients may require intravenous (IV) medication to help improve their heart failure signs and symptoms. This can be provided by the NP or by Continuing Care and this can be arranged by the clinic NP.
Following each visit The NP will provide a letter to your family practitioner detailing a plan of care and a plan for follow-up.
What happens after my first visit?
The NP will schedule follow-up visits based on your signs and symptoms of heart failure and your need for ongoing management and support. Patients will be encouraged to call the clinic if their signs/symptoms of heart failure worsen so that they can be booked for follow-up more urgently if needed.
Heart failure is a progressive disease and as patients move to end of life, palliative care will be consulted for ongoing support in order to facilitate your goals of care and comfort.