Heart failure (HF) affects 5.7 million Americans. It is Medicare’s second largest diagnosis-related group and second largest expenditure group. Studies utilizing disease management programs (DMPs) supported the use of advanced practice nurses (APNs) to successfully manage complex HF patient self-care needs in the clinic. Heart failure management is a great challenge to primary care providers (PCPs), patients, and their families. Primary care providers have knowledge gaps and uncertainty about the complex pathophysiology of HF as well as the evidence-based HF disease management program (DMP) clinical practice guidelines (CPGs) for chronic management of HF, especially in rural areas. However, DMPs are not widely implemented systematically by PCPs in urban or rural settings and thus have failed to improve costly outcomes significantly. Implementation of DMP CPGs of self-care of HF in a rural setting was the purpose for this system practice change project. The objectives were: (1) Literature-based needs assessment; (2) Practice-based needs assessment of knowledge and use of HF DMP CPGs on self-care behaviors; (3) Description of pre-implementation HF self-care behavior teaching documentation by chart audit; (4) Presentation of results of chart audit; (5) Education of APNs and staff on the project, DMP CPGs rationale, how to implement a prompt system to increase utilization and documentation of DMP CPGs; (6) Implementation of the CPGs for four months; (7) Description of the post-implementation level of HF self-care behavior teaching documentation by chart audit; (8) Presentation of chart audit results of change in utilization and documentation before and after the CPG implementation; (9) Evaluation of the success of the CPG implementation by staff questionnaires; and (10) Discussion of ways to improve implementation and plan for sustainability.
