Skip to main content
. Author manuscript; available in PMC: 2014 Jan 1.
Published in final edited form as: Heart Lung. 2012 Oct 30;42(1):32–39. doi: 10.1016/j.hrtlng.2012.08.004

Table 1. Heart Failure Telephone Coaching Program for Family Caregivers.

TELEPHONE SESSION EDUCATIONAL OBJECTIVES COACHING ACTIVITIES
Session 1: Preparing family caregiver for HF home care and reinforcing the plan of care.

  • Caregivers play an important role in maintaining the heart health of patients by encouraging patients to follow their prescribed medical regimens (take medications as ordered, follow their diet and fluid restrictions, and engage in daily exercise) and to report symptoms early to avoid rehospitalizations.

  • The nurse interventionist will assess caregiver HF educational needs.

  • Review: AHA definition of HF, signs/symptoms of worsening HF, and when to contact physician.

  • Caregiver will learn to use a checklist/calendar log for monitoring patient's HF home care.

  • Introduction - HF self-management:

  • AHA placards and magnets

  • What is heart failure? HF signs and symptoms

  • Review medication used in treatment of HF:

  • Key HF medications (ACEI, ARB, beta blocker, hydralazine/nitrate combination, aldosterone inhibitor)

  • Other HF medication (anti-arrhythmia, anticoagulant, digoxin, diuretic)

  • Setting up a plan of care for HF:

  • Use diary checklist/log to record daily monitoring of vital signs, weight, diet, fluid, fatigue, activity/exercise, medication usage, worsening HF signs/symptoms (e.g., edema/swelling, shortness of breath, fatigue)
Session 2: Working with the patient's health care team to develop problem-solving skills to conduct an efficient self-management routine.

  • The nurse will briefly review topics in the previous session and answer any questions or concerns of the caregivers.

  • The nurse will coach caregivers to prepare for doctor visits.

  • The nurse will discuss the role of the patient's HF healthcare providers and guide the caregiver to take an active role in the doctor-patient-family caregiver relationship and to report specific signs and symptoms to healthcare providers in a timely manner.

  • Caregiver will learn to develop a daily HF self-management routine and problem solve with health care providers for HF challenges.

  • Caregiver will learn about healthy nutrition guidelines/resources for people with HF.

  • Know who your HF team members are. Prepare for doctor visit and take along:

  • Recorded daily weights/BP/HF medication list

  • Written questions and list of signs & symptoms to report

  • At doctor's office:

  • Know the reason for tests/treatments/risk factors

  • Request written medical instructions/information

  • Discuss financial issues, if needed, for medication assistance

  • Develop helpful activities of daily living (ADLs):

  • Encourage patient to do for self as much as possible

  • How to assist patients with ADLs (i.e., personal hygiene, bathing, toileting)

  • Nutrition guidelines and resources for HF:

  • AHA diet & nutrition education, community meals, meals-on-wheels, food stamps
Session 3: Preventing caregiver strain and burnout and seeking professional help or support groups for caregivers managing in-home HF care.

  • Caregiver will identify challenges and learn how to avoid caregiver strain/burnout/avoid depression.

  • Caregivers will learn the signs of depression and when to seek professional help according to national guidelines.

  • The nurse will recommend home health agencies' services for in-home help with nursing care, assistance with ADLs, respite care, and/or hospice and briefly discuss who can qualify.

  • Caregivers will be able to identify which resources to contact for additional information.

  • Introduce the AHA website for caregivers www.heart.org/HEARTORG/Caregiver

  • How to avoid caregiver strain/burnout:

  • Recognize negative emotions (e.g., guilt, depression, anger), caregiver burnout (e.g., dependency, isolation)

  • Checklist to improve physical/emotional burden:

  • Take time for yourself (e.g., set realistic goals and daily priorities, regular exercise, eat balanced diet, rest, ask for help, keep a journal)

  • Long term: winning the caregiver race:

  • Seek professional help or support groups

  • Respite care, engage in outside activities

  • Getting in-home help & knowing resource information, and what to expect

  • Definitions for agencies (e.g., AHA, Medicare, state & county personal assistance programs, private pay, home health care agencies, and support groups)
Session 4: Preparing for caregiver challenges and emergency planning

  • The nurse will coach and discuss what to do in emergency situations and complete the AHA “Who to Call” emergency telephone list.

  • Family caregivers will report successes and accomplishments in HF management.

  • Briefly discuss the new caregiver website, www.healthcare.gov for insurance options; compare care quality; understand the new law and information for caregivers.

  • Prepare home care emergency plan:

  • Place Emergency Information Magnet on refrigerator for quick reference in emergencies. Emergency plan includes: 911/directions to your home, list of emergency names/numbers

  • Emergency information sheet for caregiver to carry

  • Problem-solving skills:

  • Describe step-by-step problem-solving methods

  • Identify caregiver challenges/barriers

  • Communication when the person is angry

  • Depression/boredom

  • Common fears for person with chronic illness

  • Pain management

  • Additional information:

  • Caregiver organizations, common health care terminology, common specialists