Congestive Heart Failure Care Management Guide

Content Summary

Measures: Compiled from the National Quality Forum, National Committee for Quality Assurance, Centers for Medicare and Medicaid Services, ActiveHealth Management, and more. Pathways and Guidelines: Appearing in the form of stepwise diagrams and charts, these care pathways are currently practiced as management guidelines for diabetes, and recommended by groups such as the University Health System and the Mayo Clinic. Current Tools and Encounter Forms: Refer for examples of tools used in CHF treatment contexts. Sources: 1) http://www.universityhealthsystem.com/files/03-Diuresis%20Algorithm.pdf 2) http://www.universityhealthsystem.com/files/01-Algorithm,%20Page%201.pdf 3) http://www.universityhealthsystem.com/files/02-Algorithm,%20Page%202.pdf 4) http://www.universityhealthsystem.com/files/01-Pharmacologic%20Algorithm%20for%20Acute%20Decompensated%20CHF%20%28May,%202004%29.pdf 5) http://www.lef.org/protocols/heart_circulatory/congestive_heart_failure_03.htm#treatment 6) http://www.mayoclinic.org/congestive-heart-failure/treatment.html 7) http://www.vreehealth.com/vreehealth/products/services?gclid=COGHl4LpprYCFYxaMgodY30ABw 8) http://www.rwjf.org/content/dam/farm/toolkits/toolkits/2007/rwjf27044 9) http://www.iqbalandkhansurgical.com/sitebuildercontent/sitebuilderfiles/preopencounterform.pdf 10) https://providers.amerigroup.com/ProviderDocuments/WAWA_Internal_Medicine_Encounter.pdf

Measures Used with Congestive Heart Failure

Centers for Medicare and

Medicaid Services

NQF 229: - Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following heart failure (HF) hospitalization for patients 18 and older

NQF 699: - 30-Day Post-Hospital HF Discharge Care Transition Composite Measure - scores a hospital on the incidence among its patients during the month following discharge from an inpatient stay having a primary diagnosis of heart failure for three types of events: readmissions, ED visits and evaluation and management (E&M) services.

NQF 505: - Hospital 30-day all-cause risk-standardized readmission rate (RSRR) following acute myocardial infarction (AMI) hospitalization.

NQF 698: - 30-Day Post-Hospital AMI Discharge Care Transition Composite Measure - scores a hospital on the incidence among its patients during the month following discharge from an inpatient stay having a primary diagnosis of heart failure for three types of events: readmissions, ED visits and evaluation and management (E&M) services.

NQF 330: - Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following heart failure hospitalization

NQF 521: - Heart Failure Symptoms Addressed - Percent of patients exhibiting symptoms of heart failure for whom appropriate actions were taken

American Medical

Association - Physician

Consortium for Performance Improvement (AMA-PCPI)

NQF 78: - Heart Failure (HF) : Assessment of Clinical Symptoms of Volume Overload (Excess)

NQF 83: - Heart Failure : Beta-blocker therapy for Left Ventricular Systolic Dysfunction - Percentage of patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting or at hospital discharge

NQF 81: - Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction

NQF 1524: - Assessment of Thromboembolic Risk Factors (CHADS2) - Patients with nonvalvular atrial fibrillation or atrial flutter in whom assessment of thromboembolic risk factors using the CHADS2 risk criteria has been documented

ActiveHealth Management

NQF 610: - Heart Failure - Use of ACE Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) Therapy - The percentage of patients aged 18 and older with Heart Failure who are on an ACEI or ARB

NQF 615: - Heart Failure - Use of Beta Blocker Therapy - The percentage of patients 18 years and older diagnosed with heart failure who are taking a beta blocker

NQF 624: - Atrial Fibrillation - Anticoagulation Therapy - Percentage of adult patients aged 25 and older with atrial fibrillation and major stroke risk factors who are on anticoagulation therapy.

Centers for Disease Control and Prevention

NQF 2020: - Adult Current Smoking Prevalence - Percentage of adult (age 18 and older) U.S. population that currently smoke.

Agency for Healthcare

Research and Quality

NQF 358: - Congestive Heart Failure (CHF) Mortality Rate (IQI 16) - Perecent of discharges with principal diagnosis code of CHF with in-hospital mortality

NQF 277: - Heart Failure Admission Rate (PQI 8) - Percent of county population with an admissions for heart failure.

Accountable Care Organization

ACO 10: - Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure - age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital, per 100,000 population under age 75 years

Data gathering sources for measures like ACO 10 include claims data, ICD9 codes, and service dates.

Pharmacologic Algorithm for Diuresis in CHF

Yes

No

Yes

Yes

No

No

Yes

Yes

Yes

Yes

No

No

No

No

1. Monitoring Parameters: *Weights: initially 1-2lbs weight loss per day until “ideal” weight

achieved *Volume depletion -Hypotension -Dizziness -Decreased urine output -Increased BUN (BUN/Cr > 20) *Electrolytes -Supplement K+ if <3.5 mg/dL in patient not on Digoxin and K+ <

4.0mg/dL if patient on Digoxin 2. If patient symptoms are controlled during day, but worse at night,

may need to administer diuretic regimen in evening or more frequently as needed

3. When Furosemide dose is >80-120 mg/day, use BID dosing 4. May require increase in monitoring and tighter control of K+, Mg2+

Patient volume overloaded (Sig. PND, Orthopnea, Edema)

Low Sodium diet 2 Liter Fluid Restriction Loop Diuretic (e.g.,Furosemide 40mg )

Achieve dry weight or improving symptoms,

volume status

Monitor 1,2

Lasix daily dose >

320mg?3 Double the dose

Achieve Goal?

Monitor 1,2

Add Thiazide-like Diuretic 4

CrCl >

40ml/min

HCTZ 25mg with

Furosemide

Metolazone 5mg with Furosemide 4

Achieve Dry weight or improving

symptoms, volume status

SCr <2.5 mg/dl Or

CrCL > 40 ml/min

Double HCTZ Dose

If on HCTZ switch to Metolazone 5mg. If on

Metolazone double the dose.

Achieve dry weight or improving symptoms,

volume status

Monitor 1,2

Consider admitting patient if not already in hospital for IV Furosemide

Monitor 1,2

Pharmacologic Algorithm for Congestive Heart Failure (revised 2004; page 1)

No

1. Consider Cardiology Consult, See Beta Blocker position statement

2. Target Doses: Captopril 50-100 mg TID Enalapril 10 mg BID Trandolapril 4 mg qd Fosinopril 40 mg qd 3. See Diuretic Algorithm 4. See ACE-inhibitor Position Statement 5. See ACE-inhibitor Intolerance Position Statement

Yes

Yes

Yes

No

No

Yes

Yes

Yes

No

No

No

No

Yes

No

Patients with HF symptoms: Dyspnea, Fatigue, Exercise

Intolerance

Physical Exam Assess volume Status

Determine Functional Class

Perform Echo, CXR, ECG Systolic Dysfunction

Treat HTN,CAD if present

Follow regularly to Assess response to

Treatment Q4-6 months

*Start ACE-I; Achieve Target Dose 2,4 *Diuretic if Volume Overloaded 3 *Discontinue Type I antiarrhythmics, calcium

antagonists, NSAIDs *Anticoagulate - Mobile Thrombus - Prior Thromboembolism - Atrial Fibrillation (Afib) *If Afib consider cardioversion, Amiodarone *Vtach/SCD: EPS Consult

Significant CAD

Or Valve Disease?

Refer for: Revascularization

Or Valve

Repair/Replacement Reduce CAD Risks

Consult: CT Surgery or Interventional

Cardiology Search for other causes

Nonischemic, nonvalvular CM:ETOH, drugs, HTN, low

thyroid, etc.

*Add Carvedilol1*Re-evaluate volume status and diuretic needs

*Consider Amlodipine, Felodipine Hydralazine/ISDN

*Re-evaluate volume status and diuretic needs.

ACE-I Intolerant?

SymptomsResolve

?

SymptomsResolve

?

Is patient Hypertensive

?

Follow regularly to assess response to

treatment Q-6 months

Follow regularly to assess response to

treatment Q4-6 months

Symptoms Resolve?

*Re-evaluate volume status and diuretic needs.

*Add Digoxin

Follow regularly to assess response to

treatment q 4-6 months

Hydralazine + ISDN

R/O CAD Assess Myocardial Viability

*Thallium Stress *Stress Echo

R/O Valvular disease *Cardiac Catheterization

CHF Algorithm (Con’t)

Abbreviations: HF Heart Failure CT Cardiothoracic HTN Hypertension ISDN Isosorbide dinitrate CAD Coronary artery disease NYHA New York Heart Association ACE-I Angiotensin converting enzyme inhibitors LVEF Left ventricular ejection fraction NSAID Nonsteroidal anti-inflammatory drugs CXR Chest x-ray Vtach Ventricular Tachycardia SCD Sudden cardiac death EPS Electrophysiology Service ETOH Alcohol CM Cardiomyopathy

No

Yes

Yes

Yes

Yes

No

No

Evaluate: NYHA/LVEF @ 3 months after stabilization of therapy

NYHA I?

*Consider D/C Digoxin *Continue ACE-I *Continue Carvedilol,

Metoprolol XL or Bisoprolol Follow regularly to assess response to

treatment Q 4-6 months

NYHA II or III?

NYHA IV?

*Continue Digoxin *Continue ACE-I *Adjust Diuretic *Continue Carvedilol,

Metoprolol XL or Bisoprolol1 (Carvedilol if NYHA Class IIIb) *Consider Hydralazine/ISDN *Consider Spironolactone *Research Studies *Widened QRS: Consider BiV

pacing

SymptomsResolve?

Follow regularly to assess response to

treatment Q 4-6 months

*Continue Digoxin *Continue ACE-I *Adjust Diuretic *Carvedilol (Cardiology Consult)*Consider Hydralazine /ISDN *Spironolactone *Refer for Heart Transplant *Consider Inotropes *Research Studies *Widened QRS: Consider BiV-

pacing

*Adjust Dosages *Add Remaining Drugs *Refer to CHF/Transplant Team

Page 1 of 3 Pharmacologic Algorithm for Acute Decompensated Heart Failure

Yes Yes

Yes

Yes

No

Yes

No

No Unsure No

Yes No

Yes Yes

Yes

Yes Severe AS,

HCM, restrictive CM, constrictive pericarditis, or

tamponade confirmed?

Abnormal cardiac enzymes +/-

ischemic ECG changes?

Treat as AMI or ACS • Consider cath/PCI • Consider IABP

Clinical suspicion of severe AS, HCM,

restrictive CM, constrictive pericarditis,

tamponade?

• Inotropes • Consider IABP • Cath, PCI for

suspected AMI/ACS

• Hold α HTN meds, β-blockers, ACE-I, ARB

BNP

elevated?

Cardiogenic shock or symptomatic hypotension?

• Hypoperfusion • Cool extremities • Altered mental status

Suspected acute/decompensated heart failure • History & physical, O2 sat • CXR/ECG • CBC, Chemistry, ?blood gas • Consider cardiac enzymes

Respiratory Failure

imminent?

Evidence of LV diastolic dysfunction?

• BiPAP/CPAP trial • Endotracheal intubation • If BP elevated, consider nitroglycerin, nitroprusside, nesiritide • ICU admission

Consider non-cardiac etiology

Decompensated Heart Failure

Likely?

Consider non-cardiac etiology

ECHO Refer to Diastolic

Heart Failure Pathway

Page 2 of 3

No No

No

Yes

Yes

Yes No

Yes No

No

Yes

History of LV systolic

dysfunction?ECHO

Obtain Cardiology

Consult

Evidence of LV systolic dysfunction?

Cautious hydration

Optimize SNS, RAAS antagonism

Volume depleted?

Volume overloaded?

Administer 1-2 times oral furosemide dose IV

If diuretic naïve, start with 40 mg IV furosemide

Total daily oral dose > 160 mg furosemide or

serum creatinine > 2 mg/dL?

• Diuresis and Aggressive Na+ restriction (< 2 g/day) • Consider d/c metformin, TZD’s

• D/C offending drugs Class I antiarrhythmics NSAIDS Calcium channel blockers

• Consider beta-blocker dose reduction • Supplemental oxygen • Consider anticoagulation • Consider ECHO if suspicion of

worsening pump, valve function.

Page 3 of 3

Urine output ≥ 400 mL and improved symptoms

after 2 hrs?

No

Obtain cardiology consult Initiate nesiritide 2 µg / kg loading dose followed by continuous infusion of 0.01 µg / kg / min

Urine output ≥400 mL and improved symptoms

after 2 hrs?

Yes

Yes

Optimize diuretic and ACE-I (or ARB) dose. Initiate/uptitrate beta-

blocker once euvolemic

No

Yes

Consider diuretic resistance IV bolus dose to max of 160 mg Consider continuous infusion (start at 0.1 mg/ kg/hr) after

bolus Consider addition of metolazone or hydrochlorothiazide

Re-bolus with 2 times initial IV dose at least 2 hours after first bolus

Optimize diuretic and ACE-I

(or ARB) dose Initiate / uptitrate beta-blocker once euvolemic

No

Consider diuretic resistance IV bolus dose to max of 160 mg Consider continuous infusion (start at 0.1

mg/ kg/hr) after bolus Consider metolazone or

hydrochlorothiazide Nesiritide 2 µg / kg loading dose followed by continuous infusion of 0.01 µg / kg / min

Urine output ≥ 400 mL and improved symptoms

after 2 hrs?

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Introduction

Risk Factors for CHF

Conventional Treatments For CHF

Classes Of CHF

Diagnosing CHF

Health Concerns

Page: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9

Congestive Heart Failure

Conventional Treatments For CHF

Once CHF has been diagnosed, physicians usually rely on a constellation of pharmaceuticals to address its symptoms

and slow its progression. The exact drugs used depend on the type and severity of CHF, but some of the more common

drugs include:

Diuretics — Sometimes called “water pills”, diuretics help remove excess fluid from the body. Diuretics are

often the first line of treatment. A significant side effect is the loss of potassium in urine, which may result in

electrolyte abnormalities (Braunwald 2001).

Angiotensin-converting enzyme (ACE) inhibitors — ACE inhibitors have been shown to improve survival

among patients with CHF by lowering blood pressure. Side effects include dangerously low blood pressure,

dizziness, coughing, and birth defects (Kostis 1994).

Beta blockers — Beta blockers slow the heart rate by making it less sensitive to adrenaline (epinephrine). This

medication may be given after a patient's condition has stabilized with ACE inhibitors. Side effects may include

weight gain, tiredness, dizziness, and sensitivity to cold. Patients with a slow heart rate, elevated systolic blood

pressure, peripheral vascular disease, asthma, chronic obstructive pulmonary disease, or who have had certain

heart rhythm abnormalities should not take beta blockers (Hunt 2002).

Digoxin — Digoxin is used to control symptoms of some forms of CHF and control heart rate irregularities (Hunt

2002). Side effects include abdominal pain, nausea or vomiting, diarrhea, and rarely, dangerous heart rhythm

abnormalities.

These drugs may be prescribed in an emergency setting while the physician works to stabilize the patient's condition

and in the long-term management of CHF. While these drugs are proven to extend the lives of patients with CHF, they

also cause a wide range of side effects that often require more drug therapy. Despite such intensive drug therapy, the

condition of most patients with CHF will eventually worsen, requiring more serious measures. A physician may

recommend insertion of a pacemaker or left ventricular assist device. In extreme cases, the patient may require a heart

transplant.

Vitamins and dietary supplements have also been shown to ease the symptoms of CHF—often without the debilitating

side effects of more powerful pharmaceuticals (Witte 2005). Coenzyme Q10 (CoQ10) has been widely studied in CHF

and found to increase heart function, while L-carnitine and taurine have been shown to improve cardiac function and

lessen the heart's workload (Fugh-Berman 2000; Schaffer 2000). Other dietary supplements and nutrients, including

minerals (e.g., magnesium and potassium), antioxidants (e.g., R-lipoic acid and vitamins C and E), and herbs (e.g.,

hawthorn) may help ease symptoms of CHF. Each of these will be discussed in detail later in this chapter.

The hormonal system is also affected by CHF. In the early stages of CHF, studies have shown that the body tries to

compensate for reduced cardiac function with a series of neurohormonal adaptations that work to maintain normal

blood pressure and increase the output of the heart (Dzau 1981; Dzau 1987). As the disease progresses, however, this

hormonal response is overwhelmed, and the body's delicate hormonal balance is damaged. While there is still much to

learn about the interaction of the hormonal system and CHF, hormonal therapy may offer an option for treatment.

It is important to make lifestyle changes that will slow the progression of CHF. These changes include limiting salt

intake (sometimes severely), losing weight to reduce the workload on the heart, avoiding alcohol or drugs, and

monitoring water intake. As always, no program of dietary supplementation and lifestyle changes should be launched

without the consent of a physician.

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What You Have Learned So Far...

The rate of CHF is increasing, at least partly because of our ability to treat other forms of heart disease and

partly because of the aging population.

Half of all patients with CHF die within 5 years of diagnosis.

Most patients with CHF have other underlying forms of heart disease, especially CAD. This complicates both the

diagnosis and treatment of CHF.

CHF cannot be reversed, but its severity can be improved. At best, conventional medicine uses a constellation of

powerful drugs to slow it down. These drugs have side effects that range from mild to severe and may

dramatically reduce one's quality of life.

Besides drugs, CHF can be treated with surgical interventions such as implantation of a pacemaker or even with

a heart transplant.

Some nutrients and supplements—such as CoQ10, L-carnitine, and taurine—have been shown to increase the

heart's function or reduce side effects of drugs used to treat CHF.

Lifestyle changes, including dietary modifications and avoiding drugs and alcohol (which might stress the heart),

are an important part of any heart-healthy program. Patients may also be advised to limit their intake of salt and

water.

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Ventricular assistdevice

EnlargeCardiacresynchronizationtherapy device

Enlarge

Congestive Heart Failure

Treatment

At Mayo Clinic, doctors trained in heart care (cardiologists) and cardiologists with advanced training in heart failure (heart failure cardiologists) treat people who have

congestive heart failure. Mayo Clinic cardiac surgeons have extensive experience in all types of surgery to treat heart failure and other heart diseases. Surgeons

perform minimally-invasive heart surgery, implant ventricular assist devices (VADs) and perform heart transplants.

Congestive heart failure treatment can significantly improve your symptoms and help your weakened heart work as efficiently as possible. Doctors treat some people by

correcting the underlying cause of the condition, such as controlling a fast heart rhythm, opening blocked arteries or repairing or replacing diseased valves. Heart failure

specialists also treat conditions that may aggravate your underlying heart problems, such as sleep apnea, thyroid problems, anemia and other blood abnormalities.

Congestive heart failure treatment at Mayo Clinic may include surgery, medical devices, medications and lifestyle changes.

Surgery

Heart valve repair or replacement. Cardiologists may recommend heart valve repair or replacement surgery to treat an underlying condition that led tocongestive heart failure. Heart valve surgery may relieve your symptoms and improve your quality of life.

Coronary bypass surgery. Cardiologists may recommend coronary bypass surgery to treat your congestive heart failure if your disease results fromseverely narrowed coronary arteries.

Heart transplant. Some people who have severe congestive heart failure may need a heart transplant.

Myectomy. In a myectomy, the surgeon removes part of the overgrown septal muscle in your heart to decrease the blockage that occurs in hypertrophiccardiomyopathy. Surgeons may perform myectomy when medication no longer relieves your symptoms.

Medical devices

Ventricular assist device (VAD). When your weakened heart needs help pumping blood, surgeons may implant a VAD into yourabdomen and attach it to your heart. These mechanical heart pumps can be used either as a "bridge" to heart transplant or aspermanent therapy for people who aren't candidates for a transplant. Mayo Clinic offers VADs to many people who may have noother options.

Cardiac resynchronization therapy (CRT) device (biventricular cardiac pacemaker). A cardiacresynchronization therapy device (biventricular cardiac heart pacemaker) sends specifically timedelectrical impulses to your heart's lower chambers. CRTs are suitable for people who have moderateto severe congestive heart failure and abnormal electrical conduction in the heart.

Internal cardiac defibrillator (ICD). Doctors implant ICDs under the skin to monitor and treat fast orabnormal heart rhythms (arrhythmias), which occur in some people who have heart failure. The ICDsends electrical signals to your heart if it detects a high or abnormal rhythm to shock your heart intobeating more slowly and pumping more effectively.

Medications. Doctors usually treat people who have congestive heart failure with medications proven torelieve symptoms and increase survival in people who have heart failure. Your doctor may also prescribemedications to lower blood pressure, improve circulation and prevent blocked arteries or blood thinners toprevent blood clots.

Several types of drugs may help treat your heart failure if you have reduced blood flow pumping out of your heart's main pumping chamber (left ventricle).

Angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors lower blood pressure, improve blood flow and decrease your heart's workload.

Angiotensin II (A-II) receptor blockers. These drugs provide several benefits of ACE inhibitors without the potential side effect of a persistent cough.

Beta blockers. Beta blockers slow the heart rate, lower blood pressure and lessen the risk of some abnormal heart rhythms.

Digoxin. Also known as digitalis, digoxin increases the strength of heart contractions and tends to slow your heartbeat.

Diuretics. Diuretics prevent fluid from collecting in your body and decrease fluid in your lungs, making breathing easier.

Nesiritide. Nesiritide, which is given through a vein (intravenously), is a synthetic version of B-type natriuretic peptide (BNP), a hormone that occurs naturallyin your body.

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Aldosterone antagonists. These medications may help your heart work better, reverse scarring of the heart and help prolong your life if you have severecongestive heart failure.

Inotropes. These are intravenous medications used in severe heart failure patients to improve heart pumping function and maintain blood pressure.

Sometimes congestive heart failure becomes severe enough to require hospitalization and monitoring for a few days. While you're in the hospital, you may take

medications that quickly help your heart pump better and relieve your symptoms. You may also receive supplemental oxygen. People who have severe congestive

heart failure that doesn't improve with treatment may need supplemental oxygen on a long-term basis.

Lifestyle changes. Lifestyle changes often can relieve symptoms of congestive heart failure and prevent your disease from worsening. Some changes youcan make include:

Avoiding or limiting alcohol to one drink two or three times a week

Avoiding or limiting caffeine

Eating a low-fat, low-sodium diet

Exercising by yourself or in a structured cardiac rehabilitation program

Maintaining a healthy weight or losing weight if you're overweight

Quitting smoking

Reducing stress

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Ethnicity: _____________

Language: ____________

T ____ P____ R____ BP_____ Ht_____ WT_____ BMI______ Previous Wt/date___/___

Age / gender ___________ M / F

Change in physician(s): □ yes □ no If yes, update provider list □ done Nurse’s Note: Physical Activity/Exercise:

Medications/allergies: □ updated Immunizations: : □ updated

Past Medical History: Unchanged from: ____/____/______

□ HTN □ DM □ MI □ LVSD □Dyslipidemia □ CABG □ PCI □ Implanted device

Other:

Family history:

Social History: Tobacco use: □ never □ past □ current (at present or within past 12 months)

______ Packs/day ________Duration Smoking cessation discussed: □Yes □No □ N/A

Interventions recommended: □ Yes □ No □ N/A Drug use: □ Never □ Past □ Current Type:_____________________________________________

ETOH Use: □Yes □ No Type: □ wine □ beer □ Liquor Amount:___________per day/week/month

Caffeine: □ Yes □ No ___________Cups per day/week/month? Type: ________________

CC&HPI

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□ HF

□ CAD □ Other

**********

Follow-Up

Visit Form

June 2007 Pilot Version 16 – Follow-Up Form 2

CARDIOVASCULAR SYMPTOMS: Medical Record#

Chest pain □ Yes □ No Dyspnea □ Yes □ No Orthopnea □ Yes □ No Number of pillows ________

Frequency: □ At rest

Quality: □ Mild exertion Y N PND

Level of activity: □ Moderate exertion Y N Palpitations

Intensity (scale 1-10): □ Strenuous exertion Y N Presyncope/syncope

Location: SOB with: Y N Orthostatic lightheadedness

Duration: Distance __________ Y N LE swelling

Precipitating/relief factors: Pace _____________ Y N Fatigue

Flat Uphill Stairs

Change from baseline □ Yes □ No Y=Yes, N= No

ROS: Unchanged from: _____/_____/______ (Date)

□ Cough □ Nocturia □ Nausea □ Headache □ Other

PHYSICAL EXAM:

VS: □ see previous page T ____ HR ____ BP ____ RR ____

General: □ well developed

□ no apparent distress

CV: Rhythm □ regular □ irregular

JVP □ normal □ elevated ____ cm H2O

Carotid bruits □ none □ present (□ left □ right)

PMI □ normal □ displaced laterally □ sustained

Murmurs □ none □ systolic location ____________

□ diastolic location ____________

Thrills □ none □ present location ____________

S3 □ no □ yes

S4 □ no □ yes

LE edema □ no □ yes level (ankle, knee, thigh, etc.) ____________

Lungs: □ symmetrical chest expansion

□ clear to auscultation bilaterally

□ Rales location ____________

□ wheezes location ____________

□ rhonchi location ____________

Abdomen: □ soft, nontender, nondistended

□ normal active bowel sounds

Hepatomegaly □ no □ yes

Ascites □ no □ yes

Rectal exam □ not indicated □ normal

Extremities: □ Edema 1+ 2+ 3+ 4+ location _______________

□ Warm □ cool □ cyanosis □ pallor □ skin changes_________________

Pulses: Radial Brachial Femoral Pop PT DP ALL

L 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2

R 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 □ No cyanosis or clubbing □ Full ROM of all extremities □ Normal muscle strength and tone

June 2007 Pilot Version 16 – Follow-Up Form 3

DATA REVIEW: (Laboratory / Radiology / Additional Records)

LV Systolic Function:

Last LVEF _____% Date __________ Method ____________

High risk / Known CAD?: Yes No

If yes, diabetes screening performed? Yes No Refer to Metabolic Clinic

ICD for EF < 35% Done Planned Not indicated

HF Beta-Blocker ACE/ARB Anticoagultion (Warfarin)

Prescribed, LVEF <40% Prescribed, LVEF <40%

N/A – No Paroxysmal or Chronic Atrial FibPrescribed for Paroxysmal or Chronic Atrial Fib

Prescribed Other Reasons

Prescribed Other Reasons

Not Prescribed other reasons-why not?*

Not Prescribed -Why not?*

Not Prescribed-Why not?*

Anticoagulant prescribed for other reason:________________________

*Must document reason not prescribed

CAD

Beta-Blocker ACE/ARB Antiplatelet LDL-C

Therapy Lowering Therapy

Prescribed, Prior MI

Prescribed, LVEF <40% &/or Diabetic Prescribed

Not Indicated (LDL-c <100)

Prescribed Other Reasons

Prescribed Other Reasons

Prescribed Other Reasons Prescribed

Not Prescribed- Why not?*

Not Prescribed-Why not?*

Not Prescribed- Why not?

Not Prescribed- Why not?*

**Must document reason not prescribed

Angina (CCVS) class: I II III IV

HF (NYHA) class: I II III IV

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□ HF

□ CAD

□ Other

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Follow-Up

Visit Form

June 2007 Pilot Version 16 – Follow-Up Form 4

ASSESSMENT/PLAN:

________________________________

Physician Signature

ATTENDING SUPPLEMENT:

________________________________

Physician Signature

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□ HF

□ CAD

□ Other

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Follow-Up

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June 2007 Pilot Version 16 – Follow-Up Form 5

PHYSICIAN ORDERS: Testing: BNP Chem 8 CBC Liver panel Glucose TSH

□ Lipid profile/panel (CAD) Other: (Specify)

Echocardiogram EKG X-Ray ____________________________

Heart Catheterization: Type___________ Date scheduled ___________________

Stress test type: _________________________________________________________________

Other: (specify) ___________________________________________________________________

Referrals: Cardiopulmonary rehab Other: ______________________________

Return appointment to clinic: _________________________________

Medication changes: ______________________________________________________________

Physician Signature: _______________________________________________ Date: ______________

Nurse/discharge note: Yes No N/A Comments Other

Treatment, test, procedure

F/U appointment

School/Work release

Prescriptions given

Patient Education (**if note follow-up, must include additional education):

□ Weight monitoring □ Symptom management □ Follow-up plans

□ Diet: sodium restriction □ Physical activity □ Medication instruction

□ Diet: fluid restriction □ Smoking cessation

□ Minimizing/avoiding use of NSAIDs

□ Other:

Comments:

Discharge Condition:_________________________________________________________________

Signature: _______________________________ Date:_________________ Time:___________

□ HF

□ CAD

□ Other

**********

Follow-Up

Visit Form

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BOLD Preoperative Encounter Form 

Date of Visit ____________ 

Last Name _______________________ 

Weight _____________  lbs  kgs Height _____________  in  cm 

CO­MORBIDITIES (You must select ONLY ONE per category for each system) 

First Name _______________________  Chart Number ________________ 

Hypertension No history Borderline, no medication Diagnosis of hypertension, no medication Treatment with single medication Treatment with multiple medications Poorly controlled by medications, organ damage 

Congestive Heart Failure No history or symptoms of congestive heart failure Class I: Symptoms with more than ordinary activity Class II: Symptoms with ordinary activity Class III: Symptoms with minimal activity Class IV: Symptoms at rest 

Ischemic Heart Disease No history of ischemic heart disease Abnormal ECG, no active ischemia History of MI or anti­ischemic medication PCI, CABG Active ischemia 

Angina Assessment No chest pain symptoms/angina Anginal chest with extreme exertion (e.g. running, swimming, etc.) Anginal chest pain occurs with moderate activity or exertion Anginal chest pain with minimal exertion (e.g. walking across a room) or 'at rest Unstable angina 

Peripheral Vascular Disease No symptoms of peripheral vascular disease Asymptomatic with bruit Claudication, anti­ischemic medication Transient ischemic attack, rest pain Procedure for peripheral vascular disease Stroke, loss of tissue secondary to ischemia 

Lower Extremity Edema No symptoms of lower extremity edema Intermittent lower extremity edema, not requiring treatment Symptoms requiring treatment, diuretics, elevation, or hose Stasis ulcers Disability, decreased function, hospitalization 

DVT/PE No history of DVT/PE History of DVT resolved with anticoagulation Recurrent DVT long term anticoagulation meds Previous PE Recurrent PE, decreased function, hospitalization Vena Cava filter 

CARDIOVASCULAR DISEASE 

METABOLIC Glucose Metabolism No symptoms or evidence of diabetes Elevated fasting glucose Diabetes, controlled with oral medication Diabetes, controlled with insulin Diabetes, controlled with insulin and oral medication Diabetes, with severe complications (retinopathy, neuropathy, renal failure, blindness) 

Gout Hyperuricemia No symptoms of gout/hyperuricemia Hyperuricemia, no symptoms Hyperuricemia, medications Arthropathy Destructive joints Disability, unable to walk 

Lipids (Dyslipidemia or Hyperlipidemia) Not present Present, no treatment required Controlled with lifestyle change, including Step 1 or Step 2 diet Controlled with single medication Controlled with multiple medications Not controlled 

Obstructive Sleep Apnea Syndrome No symptoms or evidence of obstructive sleep apnea syndrome Sleep apnea symptoms (negative sleep study or not done) Sleep apnea diagnosis by sleep study (no oral appliance) Sleep apnea requiring oral appliance such as CPAP Sleep apnea with significant hypoxia or oxygen dependent Sleep apnea with complications (pulmonary HTN, etc.) 

Obesity Hypoventilation Syndrome No symptoms of obesity hypoventilation Hypoxemia/hypercarbia on room air Severe hypoxemia or hypercarbia Pulmonary hypertension Right heart failure Right heart failure ­ left ventricular dysfunction 

PULMONARY Pulmonary Hypertension No symptoms or indication of pulmonary hypertension Symptoms associated with PH(tiredness, SOB, dizziness, fainting) Confirmed PH diagnosis Well controlled on anticoagulants and/or calcium channel blockers Stronger medications and/or oxygen Patient needs or has had lung transplant 

Asthma No symptoms of asthma Intermittent mild symptoms, no medication Symptoms controlled with oral inhaler (such as albuterol) Well controlled with ongoing daily medication Symptoms not well controlled, steroids or anticholinergics Hospitalized within last 2 years, history of intubation 

GASTROINTESTINAL GERD No history of GERD Intermittent or variable symptoms, no medication Intermittent medication H2 blockers or low dose PPI High dose PPI Meet criteria for antireflux surgery, or prior surgery for GERD 

Cholelithiasis No history of gallstones Gallstones with no symptoms Gallstones with intermittent symptoms Gallstones with severe symptoms or h/o cholecystectomy Gallstones with complications requiring immediate surgery prior to gastric bypass History of cholecystectomy with ongoing complications not resolved 

Liver Disease No history of liver disease Hepatomegaly modest, normal LFT's, fatty change Category 1 Modest or greater hepatomegaly, LFT alteration, fatty change Category 2 Moderate to marked hepatomegaly, fatty change Category 3, mild 

inflammation, mild fibrosis Definite NASH, cirrhosis, hepatic dysfunction by LFT's Hepatic failure, transplant indicated or done

Multiple Vitamin  Calcium  Vitamin B­12  Iron  Vitamin D  Vitamin A, D, E Combo  Calcium with Vitamin D 

CO­MORBIDITIES (continued) (You must select ONLY ONE per category for each system) 

REPRODUCTIVE Polycystic Overian Syndrome No history of polycystic ovarian syndrome Symptoms of PCOS, no treatment OCP's or anti­androgen Rx Medformin or TZD Combination therapy Infertility 

Menstrual Irregularities (not PCOS) No history of menstrual irregularities Irregular periods or oligomenorrhea Menorrhagia Amenorrhea Prior total abdominal hysterectomy 

MUSCULOSKELETAL 

Musculoskeletal Disease No symptoms of musculoskeletal disease Pain with community ambulation Non narcotic analgesia required Pain with household ambulation Surgical intervention required (ex: arthroscopy) Awaiting or past joint replacement or other disability 

Back Pain No symptoms of back pain Intermittent symptoms not requiring medical treatment Symptoms requiring non­narcotic treatment Degenerative changes or positive objective findings, symptoms requiring narcotic treatment Surgical intervention done or recommended pending weight loss Failed previous surgical intervention with existing symptoms 

Fibromyalgia No history of fibromyalgia Treatment with exercise Treatment with non­narcotic medications Treatment with narcotics Treatment with narcotics: Surgical intervention done or recommended Disabling, treatment not effective 

MEDICATIONS/VITAMINS & MINERALS 

Stress Urinary Incontinence No history of stress urinary incontinence Minimal and intermittent Frequent but not severe Daily occurrence, requires sanitary pad Disabling Operation ineffective 

Pseudotumor Cerebri No symptoms of pseudotumor cerebri Headaches with dizziness, nausea, and/or pain behind the eyes, no visual symptoms Headaches with visual symptoms and/or controlled with diuretics Patient has had MRI to confirm PTC, is well controlled with oral diuretics Patient is well controlled with stronger medications Patient requires narcotics or has had (or needs) surgical intervention 

Abdominal Hernia No hernia Asymptomatic hernia, no prior operation Symptomatic hernia with or without incarceration Successful repair Recurrent hernia or size > 15 cm Chronic evisceration through large hernia with associated complication or multiple failed hernia repairs 

GENERAL Functional Status No impairment of functional status Able to walk 200ft with assistance device (cane or crutch) Cannot walk 200ft with assistance device (cane or crutch) Requires wheelchair Bedridden 

Abdominal Skin/Pannus No symptoms Intertriginous irritation Pannus so large it interferes with ambulation Recurrent cellulitis, ulceration Surgical treatment required 

SIGNATURE (Name and Signature of person completing Encounter Form) 

Name (print) _______________________________  Signature _____________________________________ 

BOLD Preoperative Encounter Form (continued) 

PSYCHOSOCIAL Confirmed Mental Health Diagnosis None Bipolar disorder Anxiety/panic disorder Personality disorder Psychosis 

Psychosocial Impairment No impairment Mild impairment in psychosocial functioning but able to perform all primary tasks Moderate impairment in psychosocial functioning but able to perform most primary tasks Moderate impairment in psychosocial functioning and unable to perform some primary tasks Severe impairment in psychosocial functioning and unable to perform most primary tasks Severe impairment in psychosocial functioning and unable to function 

Depression No symptoms of depression Mild and episodic not requiring treatment Moderate, accompanied by some impairment, may require treatment Moderate with significant impairment, treatment indicated Severe, definitely requiring intensive treatment Severe requiring hospitalization 

Alcohol Use None  Rare  Occasional  Frequent 

Tobacco Use None  Rare  Occasional  Frequent 

Substance Abuse (Prescription or Illegal) None  Rare  Occasional  Frequent

PF-ALL-0077-12

Internal Medicine Encounter Form Mail to: Claims Department Amerigroup P.O. Box 61010 Virginia Beach, VA 23466-1010

Member Information Provider Information

Last Name: Provider Name:

First Name: Phone #: Provider ID #:

Member ID #: Date of Birth: Fax #: Date of Visit:

Address:

Level of Care: Please circle at least one CPT (Procedure) Code.

Preventive/Physical Office Visit Counseling

Age New Established New Patient

Established Patient

Code Length of Time

12–17 99384 99394 99201 99211 99401 15 minutes

18–39 99385 99395 99202 99212 99402 30 minutes

40–64 99386 99396 99203 99213 99403 45 minutes

65+ 99387 99397 99204 99214 99404 60 minutes

99205 99215

Diagnosis Codes: Please indicate primary, secondary, and tertiary codes (1, 2, 3). *If elements of well care were performed, please mark a well code as a secondary diagnosis.

Well Child/Preventive ICD-9 Codes ___ 716.90 Arthropathy, NOS ___ 244.9 Hypothyroidism

___ V70.0 Routine Physical (12+) ___ 493.9 Asthma, Unspec ___ 487.1 Influenza w/ Other Resp. Manifestations

___ V70.3 General Medical Exam ___ 724.5 Back Pain, Unspec ___ 724.2 Lower Back Pain

___ V70.5 Health Exam ___ 466.0 Bronchitis, Acute ___ 780.79 Malaise and Fatigue, Other

___ V70.6 Health Exam in Pop Survey ___ 490 Bronchitis ___ 496 Chronic Obstructed Airway (COPD)

___ V70.8 Other Specified Gen Med Exam

___ 786.50 Chest Pain ___ 729.1 Myalgia/Myositis, Unspec

___ V70.9 Gnrl Medical Exam, Unspec ___ 428.0 Congestive Heart Failure

___ 410.9 Myocardial Infarction, NOS

Counseling ICD-9 Codes ___ 372.30 Conjunctivitis, Unspec ___ 278.00 Obesity, Unspec

___ V65.3 Dietary Counseling ___ 564.0 Constipation ___ 715.90 Osteoarthrosis, Unspec

___ V65.41 Exercise ___ 780.39 Convulsions ___ 382.9 Otitis Media, Unspec

___ V65.42 Substance Use/Abuse ___ 786.2 Cough ___ 462 Pharyngitis, Acute

___ V65.43 Injury Prevention ___ 311 Depression ___ 486 Pneumonia, Organism Unspec

___ V65.44 HIV Counseling ___ 692.9 Derm. Contc/Eczema ___ 782.1 Rash

PF-ALL-0077-12

___ V65.45 STD Counseling ___ 787.91 Diarrhea ___ 477.9 Rhinitis, Allergy

Other Preventive ICD-9 Codes ___ 780.4 Dizziness/Giddiness ___ 472.0 Rhinitis, Chronic

___ V22.1 Pregnancy, Supervision Other Norm

___ 250.00 DM Type II ___ 461.9 Sinusitis, Acute

___ V22.2 Pregnant State, Incidental ___ 250.02 DM Type II, Uncontrolled

___ 473.9 Sinusitis, Chronic

___ V67.9 Follow-up Exam, Unspec ___ 786.09 Dyspnea ___ 710.0 Systemic Lupus Erythematosis

Diagnoses ___ 625.3 Dysmenorrhea ___ 305.1 Tobacco Dependence

___ 789.00 Abd Pain, Unspec ___ 558.9 Gastroenteritis ___ 463 Tonsillitis, Acute

___ 706.1 Acne ___ 530.81 Gastroesophogeal Reflux

___ 242.90 Thyrotoxicosis w/o Crisis

___ 303.91 Alcohol Dependency ___ 784.0 Headache ___ 465 URI, Acute, Mult of Unspec Site

___ 995.3 Allergy, Unspec ___ 785.2 Heart Murmur ___ 465.9 URI, Acute, Site Unspec

___ 626.0 Amenorrhea ___ 599.7 Hematuria ___ 599.0 UTI

___ 285.9 Anemia, Unspec ___ 042 HIV Disease ___ 616.10 Vaginitis & Vulvovaginitis

___ 413.9 Angina, Stable ___ 401.1 HTN, Benign Essen ___ 079.9 Other Viral Infection

___ 411.1 Angina, Unstable ___ 401.9 HTN, Essen, Unspec ___ Other

___ 300.0 Anxiety Disorder ___ 272.0 Hypercholesterolemia ___ Other

___ 714.0 Arthritis, Rheumatoid ___ 272.4 Hyperlipidemia ___ Other

Immunizations

___ 90718 DT (Adult) ___ 90658 Flu Shot (Split virus) ___ 90707 MMR

___ 90732 Pneumococcal ___ 90746 Hepatitis B (Adult) ___ Other

Laboratory Tests/Screening – For Data Collection Purposes

___ 83036 HbA1c __ 85014 Hematocrit ___ 87110 Chlamydia ___ 81000 Urinalysis

___ 85018 Hemoglobin __ 82465 Cholesterol (total)

___ 86580 Mantoux (TB) ___ 87070 Throat Culture

___ 88141 Pap Smear __ 80061 Lipid Panel ___ 82043 Microalbumin qty

___ Other

___ 85025 CBC with Diff __ 83721 LDL Cholesterol ___ 87086 Urine Culture ___ Other

Print Physician Name

Physician Signature and Date of Signature