Improving Symptoms and Quality of Life in Chronic Heart Failure: Pilot Study

The investigators will examine the feasibility of two palliative care interventions designed to improve different facets of quality of life. Briefly, the two interventions are:

• A palliative symptom management and psychosocial care intervention named Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) that includes

• evidence-based palliative symptom management of breathlessness, fatigue, and pain, provided by a nurse;
• a 6-session structured psychosocial care protocol targeting depression and adjustment to illness, supplemented by informal (family) caregiver assessment and support, provided by a social worker or psychologist; and
• brief weekly team meetings with the nurse, social worker/psychologist and a palliative care specialist, cardiologist, and primary care provider.
• A psychospiritual intervention that is home-based, self-guided, and requires minimal resources. It will be delivered in written modular form via US Mail along with brief weekly telephone support.

The specific aims of the study are to:

• Examine intervention feasibility and determine preliminary estimates of intervention effect

• Determine patient participation rates and cohort retention
• Conduct a preliminary assessment of outcomes by measuring pre-post changes in quality of life, depressive symptoms, health status, life meaning, and spirituality.
• Obtain qualitative feedback from study participants, the persons providing the intervention, and providers/leaders in primary care, mental health, palliative care, chaplaincy, and hospital operations.

Inclusion criteria

• eligible veterans from the Denver VAMC will have a prior primary discharge diagnosis of heart failure in the last year,
• be at least 18 years of age, able to read and understand English,
• have consistent access to a telephone
• at least one of the following:

• Kansas City Cardiomyopathy Questionnaire (KCCQ) score less than or equal to 60;
• a second hospitalization for with a primary discharge diagnosis of heart failure in the last year;
• taking at least 80 mg oral furosemide (or equivalent) daily in a single or divided dose for at least 2 weeks;
• BNP greater than or equal to 250 or NT-proBNP greater than or equal to 1000; or
• estimated creatinine clearance 30-80 mL/min.

Exclusion criteria

• previous diagnosis of dementia;
• active substance abuse, defined as an AUDIT-C score greater than 7, two positive responses on substance abuse screening questions, or medical records indicating active substance abuse or dependence;
• comorbid metastatic cancer, given the focus on heart failure palliative care;
• nursing home resident; and
• diagnosis of bipolar disorder or schizophrenia.