Guided Heart Failure (GUIDED-HF) Implementation Toolkit

This toolkit is designed to provide clinicians and others who provide care with patients with heart failure, especially those discharged from the emergency department, with the necessary resources to implement GUIDED-HF to promote self-care in these patients.

The resources provided should be used by those individuals who are interested in implementing GUIDED-HF in an effort to promote self-care in patients with a diagnosis of heart failure. These use resources provide guidance on best practices for implementation, common barriers that might be encountered, and potential adaptations that might be necessary.  Implementation strategies are specified according to expert recommendations and the extant literature. Resources are provided for quality assurance and the assessment of implementation outcomes.

Our hope is that these resources will help clinicians to effectively implement GUIDED-HF in their settings.

All resources are free to use unless otherwise noted.

If you have questions, please fill out the form by clicking the button below and we will get back with you with more information.

What Is GUIDED-HF?

GUIDED-HF is delivered as part of routine care for patients with a primary diagnosis of Acute HF who are discharged home from the emergency department (ED). ED providers place an order in the electronic health record (EHR) to alert team members who will serve as HF self-care coaches of an eligible patient (adult > 18 years of age; prior HF diagnosis; able to be visited and/or contacted by phone; deemed reliable to comply with self-care coaching).

Graphic representation of the GUIDED-HF intervention process

Graphic depiction of the GUIDED-HF intervention process

GUIDED-HF Information Sheet

Patients who would receive GUIDED-HF will include:

1) patients with a planned ED discharge with a primary diagnosis of AHF

3) patients with a prior HF diagnosis- patients with new-onset HF were excluded from our prior RCT.

4) able to be visited and/or contacted by phone

5) deemed reliable to comply with self-care coaching by ED provider – no history of psychiatric disease or non-adherence to follow-up.

Which patients receive GUIDED-HF? It is part of routine care for patients with a diagnosis of acute heart failure discharge to telehealth form the ED

The GUIDED-HF coach helps to: a) schedule a follow-up appointment with the patient’s provider or schedule a new appointment if they do not have a provider, b) schedule a home visit (virtual or in person) within 7 days of ED discharge, and c) phone the patient twice over the next month to work on the chosen GUIDED-HF goals:  1) establishing a daily HF routine including medication taking and weights, 2) when to contact their HF provider about symptoms of worsening HF, 3) maintaining a low-salt diet, 4) monitoring fluid intake, and 5) establishing a daily routine of exercise/activity. The total projected time based on experience to deliver GUIDED-HF is less than 4 hours over the 30 days.

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GUIDED-HF Coaching

3 GUIDED-HF Primary Coach Goals

  1. 1. Appointment with HF Clinician
  2. 2. HF Self-Care — Daily Symptoms and Weight
  3. 3. Correct Medications

Please use this link to receive more information on GUIDED-HF, provide comments or suggestions, and to reach out to research faculty. 

Implementation Materials

  • Workflow and Processes

    GUIDED-HF Implementation Workflow and Processes 

    If you would like a copy of the GUIDED-HF information sheet with more protocol details, please follow this link.

    Here is an example of a BPA we used in one of the electronic health records.

    BPA example:GUIDED-HR: BPA example

  • Measures

    Context Assessment: We used the Organizational readiness for Change Assessment and Implementation climate scale.

    Reach: we used this spreadsheet:  

    Total number of patients reached
    Site

    BPA Fired

    (Number of times the BPA fired)

    Referred to self-care coach

    (Number of patients referred by the clinician to the self-care coach)

    GUIDED scheduled

    (Number of patients who were referred and the home visit scheduled)

    GUIDED accepted

    (Number of patients who were referred and the home visit and two coaching calls completed)

    Total    

     

    Self-care coaches’ feedback using a survey: Please complete the link if you would like to obtain a copy of the survey questions.

     Patient feedback: we obtained patient input during coaching calls. Please complete the link if you would like to obtain a copy of the survey questions.

    RE-AIM measures: please complete this link to obtain more information

  • Training materials for self-care coaches and providers:

    Self-care coach resources:

    For more information, visit GUIDED-HF Coaching Resources.

  • Marketing materials for patients and staff

    (may also be used for training purposes)

     A patient brochure shares information about GUIDED-HF and can serve to increase patient awareness of potential contact by a self-care coach (or another clinician) following ED discharge.

    Heart failure resources

    PowToon videos are short 3-minute videos for patients and providers respectively and gives information about GUIDED-HF. 

    Access videos here:  Guided HF videos 

    Or VUSN You Tube