What should happen:
Hospitalized patient started on evidence based heart failure medications.
Patient's record reviewed for contraindicated medications.
Patient diuresed to predefined goals based on daily physical exam, chest xray and maybe BNP.
Patient kept in the hospital until said goals achieved.
Heart failure educator sits down with patient and family for detailed teaching (requires at least an hour face-to-face).
Long term treatment goals (medications, dosage goals, device therapy needs if applicable) based on ventricular function, functional status and heart failure guidelines discussed explicitly in the medical record at or before discharge.
Explicit plans for post discharge follow up with PCP, home health or a heart failure clinic arranged before discharge.
Early post discharge follow up.
Repeated and frequent outpatient encounters during which evidence based medications are sequentially added with each one titrated to goal.
Once goals reached, reassessment of ventricular function and prognosis to assess candidacy for device therapy.
What really happens:
Patient placed on a little dab of ACEI or ARB, or comment made in record as to why not started. Performance measure satisfied.
Patient discharged as soon as she is comfortable at rest, the vitals are stable and the labs are not too messed up.
Boiler plate heart failure instructions printed off the EMR and handed to patient as she exits the building. Performance measure satisfied.
Ambulatory PCP (if the patient is fortunate enough to have one) sees the patient on her little dab of ACEI or ARB and thinks: “She's doing well. Now's not the time to mess with her medications.”
OK, this is a caricature but you get the idea.