Moving Towards Systemness for Heart Failure Care: Nurse Navigators in the Community

Harrington Heart & Vascular Institute and UH Nursing collaborate to improve care, outcomes for patients with heart failure

Harrington Heart & Vascular Update | November 2023

Mike Nicholson was a frequent flyer until Heart Failure Navigator Lisa Dorow grounded him.

Readmitted four times within two months for acutely decompensated heart failure, this 75-year-old Vietnam veteran found an advocate in Lisa. She helped the Lorain County resident understand how to monitor his weight, sodium intake and blood pressure for the fluid buildup indicative of an ailing heart, worsened by atrial fibrillation. If he couldn’t reach his physician or needed quick advice, Lisa was available to guide him.

Mike Nicholson

“Whatever I needed, she was there,” said Mike, who also credited Lisa with facilitating scheduling of his cardioversion and ablation procedures, and helped him obtain BiPap so he sleep better. “We established a real close working relationship.”

Ashley Carlucci, DNP, MHA, RN, CEN

Eiran Gorodeski, MD,MPH

UH Nursing, in collaboration with UH Harrington Heart & Vascular Institute, has established heart failure navigators across the system. Recently, the team had a planning retreat, led by Ashley Carlucci, DNP, MHA, RN, CEN, Chief Nursing Officer for the UH East & West Markets, and Eiran Gorodeski, MD, MPH, Medical Director of the Advanced Heart Failure & Transplant Center.

“We came together to standardize roles and focus on metrics that matter to patients with heart failure and our system, in an effort to provide excellence in care to this population,” Carlucci said. “Our goal is to determine how we support better quality of life and survival of this patient population.”

Dr. Gorodeski noted that one key focus discussed at the HF navigators’ recent retreat was improving the proportion of patients with heart failure receiving appropriate guideline-directed medical therapy. Through cohesive system organization of the navigators, the team will be aligned on common metrics to ensure they are enhancing care of this patient population.

Ken Gura of North Olmsted is evidence that coordinated care benefits patients. He had been struggling with swollen ankles and trouble sleeping because he couldn’t lay down. UH St. John’s HF navigator was the first healthcare professional to utter the words heart failure to him after he landed in the Emergency Department last summer. Ken was diagnosed with advanced heart failure.

Only 51 and in denial, it was the amount of time Lisa spent explaining the condition to Ken and his wife that helped him grasp his new reality.

“I was not expecting the diagnosis she was giving me,” said Ken, a two-pack-a-day smoker for more than 30 years who had previously escaped any cardiac problems. “She spent at least two hours with me, going over things. That’s when I started taking this more seriously, and that’s when it really started sinking in. Being your typical guy, I didn’t want to accept reality.”

After a repeat ED visit, Ken was transferred to UH Cleveland Medical Center, where after extensive evaluation he was advised to be listed for heart transplantation. This avid baseball fan, diagnosed well after the July All-Star Break, had a new heart before the regular season ended in September.

“It finally kicked in that this is a heck of a lot more serious than I gave it credit for,” said Ken, whose father had a heart transplant in his early 60s due to heart failure. “Everything went into light-speed when I went downtown. It was a whirlwind. It was pretty amazing, the whole experience.”