Table 1.

List of Evidence Based Statements (In order of priority identified by nurses in focus groups)

Ranking	Statement (potential format of feedback)
1	Track vital signs, lung sounds, activity tolerance, frequency of symptoms, weights/weight changes daily. Pay special attention to fluid overload. Notify MD if weight gain over 3lbs overnight, and over 5lbs in 7 or fewer days (pattern of symptoms – weights over time, fatigue over time)
2	Provide heart failure care log (vital signs, weight log, medication list, dietary log) (have they got the log Y/N?)
3	Determine risk of hospitalization at SOC/ROC – provide frontloaded contacts for patients with risk of ≥5 for hospitalization for the first 2 weeks of care (patient is at risk of hospitalization Y/N; If Y- then monitoring of frequency of visits, alert if needs one)
4	Every patient with HF should have clear, detailed, evidence-based plan of care (do they have a care plan? Y/N; is it up to date and detailed? Y/N)
5	Develop system for medication management have a system of medication management in place Y/N)
6	Assess learning needs and identify barriers. Educate about importance of adherence (carried out assessment of learning needs Y/N; feedback on education provided Y/N)
7	Coach patient on early symptom management and actions to take at each visit (have carried out education on symptom management Y/N)
8	Reconcile medications at SOC/ROC (medications have been reconciled Y/N)
9	Evaluate every visit, document changes and actions taken
10	Coach patient to schedule follow up visit within 7 days of discharge (has had follow up visit Y/N)
11	Sodium intake – read food labels, avoid high sodium foods, avoid adding sodium to meals (advice given Y/N)
12	Understand disease processes and link signs and symptoms to disease and behavioral choices (patient is able to do this Y/N)
13	Plan care based on patient stated reason for hospitalization/home care and patient stated goals (has plan Y/N)
14	Develop action plan for how to notify MD (has an action plan and patient knows what to do Y/N)
15	HF patients should be vaccinated against influenza and pneumococcal disease (have they had a vaccination? Y/N; if not have you organized for it be carried out? Y/N)
16	Evaluate for telehealth (do they need telehealth Y/N – have they been referred and has it been installed Y/N)
17	Evaluate need for social work and behavioral health if patient has depression (alert if screened for depression – then have they been referred to SW/BH Y/N)
18	Clarify if using any medications causing adverse effects – diuretics, NSAIDS, OTC drugs (checked for OTC, NSAID use Y/N)
19	Assess need for palliative/hospice care for patients with advanced HF (is patient in advanced HF? Y/N; if Y have you discussed palliative/hospice care Y/N)
20	Assist patient to identify self-care goals (specific, realistic, measurable) (has the patient got self-care goals? Y/N)
21*	Clarify fluid orders with MD (clarified/not clarified)
21*	Evaluate need for nutritionist referral (referral needed Y/N; referral made Y/N)
21*	Avoid use of high potassium salt substitutes (advice given Y/N)
21*	Routine serum electrolytes – serial measurement of serum potassium, routing renal function (alert when routine laboratory tests required)
21*	Assess functional status/mental status (assessment carried out and documented Y/N)
21*	Obtain diet orders – restriction of sodium (orders sent/not sent)
21*	Exercise training as safe and effective adhere to guidelines. Regular physical activity is strongly recommended for patients with CHF (monitoring of physical activity over time)
21*	Cardiac rehab in clinically stable patients (they have been referred to cardiac rehab if appropriate Y/N)

^*none of these statements were identified as priorities during focus group interviews

SOC: Start of Care

ROC: Resumption of Care