Heart Failure and the Continuum of Care

A senior man and woman doing heart failure rehabilitation exercises with the help of a physical therapist

The cost of heart failure is going up. While medical advances in the last decade have contributed to a decrease in the total number of hospitalizations with a primary diagnosis of heart failure, or HF, the overall expense is increasing.

According to a recent study, the financial burden of heart failure in the United States was estimated at $20.9 billion in direct costs in 2012. Between 2012 and 2030, that cost is expected to rise from 154% to $53.1 billion—a figure that, while staggering, is also incomplete, as it fails to account for the incalculable loss suffered by families and individuals affected by HF.

However, strong evidence shows that interventions within the scope of practice of most rehabilitative therapists can improve the quality of life for people with HF. Clinicians have within their skill set the tools to strengthen not only their patient’s functional performance, but also their well-being.

Here is a clinician’s guide to examination, assessment, and intervention.

Continuum of failure, continuum of care

A physician’s physical examination is required to diagnose HF, and the result of that exam may impact a clinician’s evaluation and treatment plan. As with many conditions, the severity of HF can vary. For example:

  • A patient categorized as Class I on the NYHA Classification of Heart Failure scale may have cardiac disease, but ordinary physical activity causes them no pain, and their everyday activities are not limited.
  • On the other hand, a patient categorized as Class IV on the NYHA scale may not be able to perform any physical activity without discomfort and an increased severity of symptoms.

Effective interventions for each of these patients must be tailored to their needs, as well as additional risk factors, which come in two categories: nonmodifiable risks (sex, age, anemia, structural abnormalities, etc.) and modifiable risks (hypertension, obesity, diabetes, smoking, etc.).

As experts in exercise and activity, rehabilitation professionals play a role in encouraging healthy lifestyles, which may mitigate modifiable risk factors.

To learn more about heart failure and physical therapy, enroll in our CE course: Heart Failure: Implications for Diagnosis, Medical Management, and Rehabilitation, 2nd Edition.

Patient assessment

When performing a patient assessment, a clinician should come away with three things: a clear picture of those areas suited to rehabilitation interventions, the areas where further medical management or referral sources are needed, and specific, measurable patient goals.

Asking the right questions

Begin with questions that establish a patient’s baseline activity tolerance. Initial questions might include: “Prior to admission, did you do any regular physical activity or exercise?” or “Lately, what barriers have you noticed that keep you from doing more?”

Note the contrasting time frames in these questions. In structuring the interview this way, a clinician will gain a better understanding of the patient’s activity level over time.

Also critical are questions around contextual factors. No patient exists in a vacuum, and family support, living environment, and prior participation in a pulmonary or cardiac rehabilitation setting will all play a role in his or her intervention.

Starting an interview with questions like these can help a clinician develop a good working diagnosis and intervention plan before even performing a patient physical examination.

From head to foot

Heart failure impacts the entire body. Given the scope of this systemic dysfunction, patients with HF require a comprehensive physical examination before, during, and after daily activity—a level of scrutiny not commonly performed during a visit to a physician.

An effective clinician assessment should take into consideration the following categories:

  • Neurologic and cognitive
  • Gastrointestinal and nutritional
  • Integumentary
  • Pulmonary
  • Cardiovascular
  • Musculoskeletal and functional

Interventions

The goal of a successful intervention for patients with HF is threefold: first, to relieve symptoms and signs of active HF; second, to prevent hospital readmission (and thus help reduce spiraling healthcare costs); and third, to improve not only survival rates, but also the patient’s quality of life.

Common interventions may include aerobic and strength-training exercises to ventilatory muscle training, all adapted to the patient’s needs, abilities, and existing limitations.

Dignity and care to the end

Heart failure is a progressive health condition. While rehabilitation professionals play a critical role in helping patients improve and maintain functional performance, they may also serve as part of a transdisciplinary team including social workers, chaplains, and other clinicians, providing palliative caring for a patient at the end of his or her life.

This article is based on the 6-hour Physical Therapy CE course “Heart Failure: Implications for Diagnosis, Medical Management, and Rehabilitation, 2nd Edition,” written by Paul E. H. Ricard, PT, DPT, CCS.

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