Clinician-to-Clinician Update Clinician-to-Clinician Update

Empowering Heart Failure Patients to Manage Their Condition and Thrive

February 2017

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— Heart failure management programs include ongoing monitoring and patient education in the effort to improve outcomes. C.O.R.E. Clinic clinician Sara More, PA-C, MS, BS, pictured.

Outpatient programs are reducing hospital readmissions and extending quality of life for patients with chronic heart failure (CHF).1 Among adults 65 years of age or older, heart failure remains the leading cause of hospitalization. Despite improvements in treatments for heart failure, readmission rates within 6-months of initial discharge are high, up to 50%.2 To improve these outcomes, outpatient clinics are employing a multidisciplinary, patient-centered approach to CHF, incorporating lifestyle management and care support to the ongoing assessment and medical treatment of CHF and cardiomyopathy.2

Heart patients who remain engaged in their care stay active longer and are admitted to the hospital less often.3 Models of care have changed over time to place more emphasis on chronic management of patients with heart conditions, with the goal of improving outcomes and helping these patients avoid repeat visits to emergency departments and intensive care units. Outpatient heart failure management programs have incorporated ongoing monitoring, treatment, and patient education in helping patients manage their cardiac care over the long term.4

University of Minnesota Health’s C.O.R.E. Clinic for Heart Failure Management takes this multidisciplinary, individually tailored approach to providing long-term care for patients with CHF. (The clinic name stands for cardiomyopathy optimization, rehabilitation, and education.) The C.O.R.E. Clinic combines aggressive monitoring and adjustments to treatment with lessons in lifestyle management and support in removing barriers to care. The 5-phase program—consisting of evaluation, optimization of care, resynchronization, stabilization, and restabilization—provides a structured approach to the management of CHF.

Patients entering the clinic are evaluated to determine the severity of their heart condition and to identify any necessary medication adjustments. To optimize care, patients attend outpatient visits with advanced practice providers. Patients also have visits with advanced practice providers between visits with their physician. Each patient receives one-on-one education about his or her treatment, exercise, and rehabilitation plans. The patient education might include lessons in how to use self-monitoring tools, such as the telemedicine system. Telassurance, an 800 phone number, lets patients call in daily to answer 5 symptom-based questions on their health status. If any of their symptoms raise a flag, patients can call the C.O.R.E. Clinic nurse line directly and talk to a clinic staff member.

In the resynchronization phase, patients are evaluated for heart rhythm problems and to determine whether they might benefit from a pacemaker or defibrillator. Patients also receive periodic follow-up evaluations to help stable patients maintain their condition and to diagnose and treat problems before they become serious. If CHF symptoms return, advanced home health care and monitoring are available.

This intensive, patient-centered approach has brought national recognition as a top-performing program and improved patient outcomes. For heart failure patients in C.O.R.E. Clinic locations, rates of hospital readmission and the observed to expected ratio for mortality are up to 40% lower than the national average for patients with CHF. (See Specialty Updates)


  1. Cowie MR. Postdischarge assessment and management of patients with heart failure. Medicographia. 2015;37:155-162.
  2. Desai AS, Stevenson LW. Rehospitalization for heart failure. Circulation. 2012;126:501-506.
  3. Corotto PS, McCarey MM, Adams S, et al. Heart failure patient adherence. Heart Fail Clin. 2013;9(1):49-58.
  4. McDonald K, Conlon C, Ledwidge M. Disease management programs for heart failure: Not just for the “sick” heart failure population. Eur J Heart Fail. 2007;9:113-117.

When to refer

The University of Minnesota Health Heart Care C.O.R.E. Clinic treats patients who have been hospitalized or who are at risk of hospitalization due to chronic heart failure or cardiomyopathy. Our comprehensive outpatient program is designed to improve each patient’s quality of life and to prevent the need for readmissions to the hospital due to a patient’s heart diagnosis. Our clinicians believe that each heart patient is unique. Our advanced practice providers, including nurse practitioners and physician assistants, deliver expert individualized care planning and education for each patient. Our teams work together to monitor patients who may need changes to their medication or evaluation for implantable device therapy or valve therapy. We offer support for the implementation of lifestyle changes as well as patient self-monitoring tools. We also coordinate home-based support for chronic heart failure patients with physical, cognitive, or financial limitations.

To schedule a consultation or refer a patient, contact us at 612-365-5000 or toll free 877-650-1555.

Multidisciplinary, Collaborative Care

Clinicians in the C.O.R.E. Clinic participate in a comprehensive, coordinated outpatient program. Our clinicians maintain frequent collaboration with the primary care physician to coordinate treatment and to address any co-occurring medical conditions that may impact the patient’s heart condition. Because many patients with chronic heart failure struggle with other medical conditions, our clinicians are in regular contact with pharmacists, nephrologists, pulmonologists, and oncologists.

Our clinicians are dedicated to working with you to achieve our primary goal: empowering people living with heart failure to improve their quality of life.

To find current clinical trials available through M Health providers, visit

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