Heart Failure Care Management Modules

A series of tutorials on the essential components for patient-centered heart failure care.


Over six million people in the United States have heart failure, and approximately half will die within 5 years of their initial diagnosis. Heart failure is one of the most expensive diagnoses costing the US healthcare system over $30 billion each year. It’s prevalence is steadily increasing due to an aging population and a rise in conditions that contribute to the development of heart failure, including obesity, hypertension, and diabetes.* To optimize patient longevity and quality of life while limiting costs, it is imperative that heart failure is diagnosed early on and patients are treated with guideline-directed medical therapy.

The Heart Failure Care Management Modules provide a framework for healthcare professionals and students interested in learning about up-to-date guidelines for heart failure care. Developed through an academic-practice partnership between the University of Washington (UW) School of Nursing (SON) and UW Medicine’s Regional Heart Center (RHC), topics covered in this series were specifically chosen to enhance clinical practice and improve heart failure outcomes throughout the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region and beyond. The self-paced modules are freely accessible and may be completed in any order. Additional modules will be added as they are completed.

For additional resources on heart failure clinical practice, please visit the Northwest Heart Failure Collaborative: Project ECHO web page.

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Learning Objectives:

  1. Define advanced heart failure (HF), goals of care discussion, and shared decision making.
  2. Outline the trajectory of HF illness and anticipated decision points.
  3. Identify triggers for goals of care conversations.
  4. Recognize potential barriers to patient-provider communication in advanced HF.
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Learning Objectives:

  1. Become familiar with prevalence of cognitive impairment in Heart Failure patients.
  2. Understand how to screen for cognitive impairment.
  3. Learn how to administer, score and interpret results of the Mini-Cog™, AD8 and PhQ-2 screening instruments.
  4. Rule out comorbidities and identify contributing factors that may affect cognition in heart failure such as cardiovascular pathology, medications, or the presence of depression.
  5. Disclose clinical findings to patients and families.
  6. Formulate diagnosis, treatment plan and initiating referrals.
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Learning Objectives:

  1. Define telehealth terminology.
  2. Describe the history of telehealth.
  3. Discuss current guidelines and anticipated benefits for home telehealth.
  4. Analyze effective telehealth in a person with heart failure.
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Learning Objectives:

  1. Describe key symptoms of depression and tools used in assessment of depression in Heart Failure (HF).
  2. Identify treatment options for patients with depression and HF.
  3. Describe interprofessional team roles for treatment of depression in patients with HF.
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Learners are presented with information as the providers learn of the patient’s emergent and ongoing health concerns, and asked to make decisions about how to care for this patient.

Authors: Angela D. Pal, PhD, RN, ARNP; Hilaire J. Thompson, PhD, RN, ARNP; Joelle T. Fathi, DNP, ARNP; Phyllis Christianson, MN, ARNP; Leigh Ann Mike, PharmD, BCPS; Megan Moore, PhD, MSW; Janet Lenart, RN, MN, MPH; Kumhee Ro, DNP, ARNP; Patricia Kritek, MD, EdM; Marni Levy, BS

© 2017 University of Washington | School of Nursing | L&IT Interactive Production Web Services

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Learning Objectives:

  1. Define implicit and explicit bias
  2. Identify how bias operates in clinical settings
  3. Apply strategies to mitigate impact of bias
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Learning Objectives:

  1. Discuss physical functioning and psychological adjustment following an ICD.
  2. Explore cognitive and relationship challenges following an ICD.
  3. Suggest helpful strategies to the patient to enhance adjustment following an ICD.


Titler, M.F., Jensen, G.A., Dochterman, J.M., et al. (2008). Cost of hospital care for older adults with heart failure: medical, pharmaceutical, and nursing costs. Health Services Research, 43, 635-655.


This website is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $2,090,495 with 0 percentage financed with non-governmental sources. 

The MANAGEMENT OF ACUTE HEART FAILURE FROM ADMISSION TO TRANSITION module was produced with support from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number D09HP26957, “Preparing Acute Care Nurse Practitioners for Care of Adults and Older Adults with Multiple Chronic Conditions” for $736,031.

This information or content and conclusions are those of the author(s) and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.