How Exeter Hospital's congestive heart failure clinic works to improve lives and outcomes

EXETER — Cardiac care experts at Exeter Hospital say patients can avoid frequent hospitalizations and can live with a better quality of life if they accept the parameters of their disease and take the steps needed to be healthier.

To that end, a heart health clinic for patients diagnosed with congestive heart failure is taking place at Exeter Hospital, and it is making a difference, leaders say. The clinic personnel say their data show people who take part in the clinic and follow the advice given there translates into fewer hospitalizations and more patients who are living their best lives.

"There is a lot of misconception about CHF," said Dr. Brian Porter, a cardiologist at Exeter Hospital. "People hear heart failure and think you die. In congestive heart failure, the problem is more of a pumping inefficiency. A person can die, but if treated properly, it is a disease, and one that can be better managed."

What is congestive heart failure?

Congestive heart failure indicates there is congestion, a buildup of fluids due to an inefficiency in the way the heart functions, and that can be caused by several problems. 

"The heart, which is a muscle, can be tired, worn out or weak," said Porter. "Some people get a stiff heart, particularly if they have high blood pressure or diabetes."

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Porter said the heart muscle functions properly by squeezing blood out to the body and then relaxing, and expanding again to fill. 

"Some hearts squeeze too hard and then do not relax," he said. "Fluid builds up and that is diastolic heart failure. Valvular heart failure happens when fluid builds up from a failure to circulate blood. There are four valves in the heart and there can be stenosis (sticky valves) or regurgitation (leaky valve). The effect is the same, fluid buildup."

The treatment depends on the source of the problem, but patients can help themselves to some extent.

Porter said Exeter Hospital started the congestive heart failure clinic in 2017 and the staff is quite proud of the impact it has had on patients.

"We recognized that CHF patients seemed to be hospitalized more than should have been needed, so we looked at that," said Porter. "They were not having the healthy outcomes we felt they should be having so we began looking at why. We looked to their lifestyles and ways we could bring bring extra resources to bear that would improve the quality of their health and reduce hospitalizations. The ultimate goal is to improve the quality of life for our CHF patients."

How the clinic team provides care for each patient

Peter Shactman is a physician's assistant and primarily responsible for following the progress of the clinic's patients.

"There has traditionally been a problem in that there is a lot of readmission to the hospital for CHF patients," said Shactman. "After studying the issue, I was hired to be the face of the clinic on a daily basis. My role is to provide a lot of support and a multidisciplinary approach to treatment. We hoped it would reduce readmissions, and it has."

Shactman said Sandy Furtado, a registered nurse, manages complex care plans for each patient and speaks with them at least weekly. 

"We create an action plan based on their needs," said Shactman. "They weigh in daily because changes in weight can be a good indicator of where they are in their health. We put them on a low sodium diet which helps to prevent fluid buildup. Patients are offered participation in nutrition classes over Webex, with Beth Devaney, one of our registered dieticians."

Shactman said they use a whole person approach, so patients meet with palliative care experts to learn how to be more confident in the way they approach their health. He said they educate patients so they recognize danger signs quicker, possibly dealing with them without the need to go to the hospital.

"We look at the psychosocial aspects," he said. "We look also at their family dynamic. Weight gains, shortness of breath and taking their medications are indicators we watch as is their fluid and salt intake, which helps reduce and prevent fluid buildup."

"We hired Peter to provide that one-on-one care for the patients who came to the clinic," said Porter. 'He sees them in the office or virtually, keeping a close eye on them, on their diet, nutrition. They meet with a palliative care specialist and social workers to address all their needs. We developed a checklist to use each time. That and our scientifically proven methods to treat CHF is making a difference." 

Porter said they were stunned at how successful the clinic was. 

"We have lowered our admission rates," said Shactman. "They are actually well below the initial target rate for unplanned admissions we set for the clinic. Our patients report that they feel their quality of life has consistently gone up since they have been taking part in the CHF clinic."