L.H. is a 76-year-old man with a history of coronary artery disease and multiple myocardial infarctions for which he received several stents prior to having coronary artery bypass surgery. He had a history of aortic stenosis and had undergone aortic valve replacement. His prior myocardial infarctions left him with an ischemic cardiomyopathy with an ejection fraction of 20% to 25%. His cardiovascular risk factors included hypertension and hyperlipidemia. In the 2 months following his coronary artery bypass surgery, Mr. H. was admitted to the hospital three times for congestive heart failure. He lived alone and ate fast food most of the time; he also had a friend who cooked high-sodium Southern favorites for him, such as biscuits and gravy. He endorsed adherence to his medications and attended all of his scheduled follow-up visits. He was seen by a nutritionist during his first readmission.
Mr. H. participated in a remote patient monitoring program and was seen in an advanced heart failure clinic. He expressed frustration with his frequent readmissions and monitored his daily weights with his nurse care coordinator very closely. During one conversation with his nurse care coordinator regarding a 3-pound weight gain from the previous day, the nurse asked him to do a 24-hour food recall. When she asked about his sodium and fluid restrictions, the nurse discovered that Mr. H. had a knowledge deficit about hidden sources of sodium. He had eaten a sandwich at a fast food establishment the previous day containing 1500 mg of sodium, although he thought he was making a heart-healthy choice. After the nurse coordinator told him that one 6-inch sandwich contained three-fourths of the sodium he should eat in an entire day, Mr. H. became more vigilant about tracking the sodium in the foods he ate.
The nurse care coordinator and the nurse practitioner in the heart failure clinic worked closely with Mr. H. to optimize his outpatient diuresis, to help him recognize symptoms of fluid overload, and to teach him to monitor his daily fluid intake and sodium consumption. Mr. H.'s weight and symptoms stabilized, and he became highly engaged in tracking his weight, fluid intake, and the sodium content in his food. On more than one occasion when his nurse care coordinator called him to discuss a mild weight gain, he answered the phone with “I knew you were going to call; let me explain.”
Mr. H. finished his remote patient monitoring program without being readmitted again. He called his nurse care coordinator about a month after finishing the program and stated he was meeting friends at Cracker Barrel for lunch and that their website was down so he wasn’t sure what to order. He asked the nurse, “What should I do?” After joking, “Don’t go to Cracker Barrel,” the nurse gave him general guidance for high-sodium “key words” and for healthier options.
Mr. H. follows up with his providers regularly, still weighs himself daily, and hasn’t been admitted for heart failure for over a year and a ...