Closing Gaps in Care: FMH Heart Bridge Clinic

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Last summer, Daniel Havens was chronically exhausted, constantly short of breath and frequently in pain. In early September of 2012, he collapsed. Tests revealed that he had congestive heart failure.

This was the beginning of an unfortunate, 3-month medical odyssey for the 61-year-old retired construction worker. From a hospital in Baltimore he was transferred repeatedly to rehabilitation centers and other hospitals, making little to no progress. He returned to his home in Frederick several days after Christmas last year– still seriously ill, and still without a plan of care.

In March of 2013, Mr. Havens visited the FMH Emergency Department for yet another acute episode. This time his pattern of recurring hospitalizations for heart failure was noted. While in the hospital, nurse practitioner Kathy Troupe from the hospital’s Heart Failure Program visited him. She spoke to Mr. Havens and his wife about his condition, and things that could be done to improve it— information and advice the couple said was new to them, and that they found very helpful. A plan of care was developed that included a follow-up appointment with Troupe at the FMH Heart Bridge Clinic—the hospital’s free clinic where patients without traditional follow-up care can be examined and evaluated within 3-5 days after discharge.

“When improperly managed, heart failure spirals out of control very quickly,” said Troupe. “Following discharge instructions and getting prompt follow-up care is critical. Through the Heart Failure program and the Heart Bridge Clinic, we are able to give patients the tools and support they need to start feeling better—and stay out of the hospital.”

Heart Failure At a Glance

One of its most common symptoms is shortness of breath. It may be accompanied by mild to severe dizziness or fatigue, and swelling in the legs, ankles and feet. Some patients have congested lungs, a rapid or irregular heartbeat, and an overall feeling of weakness and malaise.

The condition is called “heart failure,” and it’s the robber of health and vitality in nearly 6 million Americans. It’s also the most common discharge diagnosis among Medicare beneficiaries, and the third highest request for hospital reimbursements across the country. Alarmingly, up to 20 percent of patients hospitalized with heart failure are readmitted within 30 days, making it the leading cause of repeat hospitalizations in the US.

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