Supporting the Client’s Journey to Successful Heart Failure Management

The Nanaimo Heart Function Clinic Model

Submitted by: Madelene Daniel

Heart failure is a chronic condition that requires chronic disease management (CDM).  People living with heart failure tend to have co-morbid conditions and concerns that go beyond learning about daily weights, sodium monitoring and fluid restriction. As a heart function clinic (HFC) spoke, within Vancouver Island Health and under the auspice of the Provincial HF strategy HUB and Spoke Model of HF service delivery, the Nanaimo HFC, is an excellent example of how a spoke HFC clinic can provide comprehensive HF care within a CDM care model.

CDM is an approach to healthcare that emphasizes helping individuals maintain independence and keep as healthy as possible through prevention, early detection, and management of chronic conditions (Vancouver Island Health Authority [VIHA], 2011). The Expanded Chronic Care Model (ECCM), the model adopted by the Provincial Heart Failure network, shifts healthcare delivery to a client-centered focus. This model includes the client as an integral part of the care team who collaborates with their healthcare providers in making decisions about their healthcare (Barr et al., 2003). This approach to providing CDM was recently reinforced during the Vancouver Island Health Authorities Patient Journey Mapping (PJM) experience. outcomes of the PJM sessions included participants validating their need to be an informed active member of their healthcare team and wanting to be part of the decision making for their healthcare.  Furthermore, participants described themselves as co-managers of their chronic condition citing the term self-management as being a “lonely” term.

Cornerstone to effective CDM is self-management support (SMS) – those interventions clinicians provide to increase the client’s knowledge and confidence in co-managing their health. It includes regular assessments of client’s progress and problems, goal setting, and problem-solving support (Adams, Greiner, & Corrigan [2004] as cited in McGowan [2005]). SMS is a core component and strategy of the ECCM (Barr et al., 2003) and the Nanaimo HFC.

In the Nanaimo HFC , client experience initially begins with a 1-1.5 hour 1:1 session with the HFC clinic registered nurse. The 1:1 session consists of education on how the heart functions, what is HF, HF medications and discussion and  identification of lifestyle changes that need to be managed. In addition, time is spent reviewing the client’s personal story, their risk factors, their supports at home and their needs and expectations. The RN begins the session with “We have about an hour and I know what I want to talk about with you today, but what concerns or questions do you have that you want addressed today?” Taking time to listen and understand the clients lived experience creates the foundation for building a trusting nurse/Client relationship. This trusting relationship is the basis for providing a culturally sensitive environment, supporting the client to feel comfortable in sharing their true feelings and concerns. It also empowers the client to feel confident in their ability to make the necessary life changes and become actively engaged in co-managing their care. Education tools created by the Provincial HF Network Resource Development working group have been adopted by our clinic. Clients are encouraged to use them as references to guide their self care. The second clinic visit follows within 2-6 weeks of the first visit and includes a 30 minute session with the HFC Internist as well as a 15 minute session with the RN who checks vital signs, asks a series of questions and undergoes medication reconciliation. With every clinic visit, the RN reviews how the client is managing their HF and their other chronic conditions on a day- to-day basis. The clinic visit snapshot form is used to capture all changes in care and future tests and is given to the client as a take home information sheet/personalized care plan and serves as a communication sheet for the client to show their primary care providers. A formal physician consultation progress report is also sent to the primary care practitioner.

The biggest challenge the Nanaimo HFC faces is the ever increasing number of new referrals. As the need for HF care grows, it will become increasingly more difficult to provide the 1:1 intake education session with the nurse clinician. However having a delivery system that supports the nurse clinician’s time to build a trusting relationship and thereby prepare and empower the client to co-manage their condition(s) at home is the goal of CDM and the overall goal of the Nanaimo HFC.



1.     Barr et al. (2003). The expanded chronic care model: An integration of concepts and strategies from population health promotion and the chronic care model. Hospital Quarterly 7(1), 73-83.

2.    McGowan, P. (2005). Patient self-management. Background paper to the new Perspectives: International Conference on Patient Self-Management. Victoria, BC. September 2005.

3.   VIHA, (2011). What is chronic disease management to VIHA? Retrieved November 13, 2011 from:



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