Self-Management and Care of Heart Failure With Group Clinics (SMAC-HF)

Aim 1 Hypothesis:

• The time to the 1st composite endpoint (HF Rehospitalization/death) will be longer for HFcareGroup than standard care group at 12 months.
• The HFcareGroup will have higher score than standard care on patient outcomes i.e. functional health status, quality of life, satisfaction with health care at 12 months.
• Health Services Use will be lower in HFcareGroup than standard care group at 12 months.

Aim 2 Hypothesis:

• The HFcareGroup will have higher score than standard care on patients' HF self-management i.e., self-care behaviors, participation with health care professionals in HF management and problem-solving, HF knowledge and preparedness for home care at 6 and 12 months.
• A greater proportion of HFcareGroup vs standard care subjects will report clinical or symptoms of HF decompensation (e.g. specific weight gain, shortness of breath, edema, fatigue, tachycardia, and medication side effects) to their health care provider.

Inclusion criteria

• 18 years or older
• speak English/Spanish
• receiving treatment for congestive heart failure
• receiving IV diuretics
• 2 or more HF symptoms
• be able to participate in follow up visits

Exclusion criteria

• primary right-sided heart failure
• HF transient & related to acute MI
• HF due to correctable cause
• being scheduled for coronary revascularization or any readmission
• receiving infusion for HF therapy within 2 weeks
• having co-morbidities, life expectancy < 12 months
• severe cognitive impairment
• D/C to nursing facilities or rehab unit
• Currently enrolled in an intervention study or HF management program
• being or planning to become pregnant within 12 months
• severe cognitive impairment