HeartStrong™ Heart Failure Recovery Program

Trusted heart failure support at home that strengthens daily stability, prevents flare-ups, and reduces avoidable readmissions through structured monitoring, medication safety, and tight physician coordination.

HeartStrong™

HeartStrong™ Care Support at Home

Ideal for patients with:

Recent hospital or SNF discharge for CHF exacerbation or fluid overload

New or adjusted diuretics or complex cardiac medications

Shortness of breath, swelling, fatigue, or reduced activity tolerance

Frequent hospitalizations or recent ER visits for heart failure symptoms

Multiple chronic conditions affecting stability (COPD, CKD, diabetes)

Difficulty managing meds, diet, or daily monitoring without support

Caregiver needs education and a clear action plan at home

What Makes HeartStrong™ Different

Standardized daily monitoring workflow with clear “when to call” thresholds
Medication reconciliation focused on high-risk cardiac meds and adherence
Teach-back coaching that builds real confidence for patients and caregivers
Fast escalation playbook for early symptoms before they become admissions
Tight coordination with cardiology/PCP for plan changes and follow-up
Consistent documentation that supports continuity and coverage

HeartStrong™

The HeartStrong™ Care Approach

Clinical Care

Complete heart failure baseline assessment at start of care

Monitor symptoms, edema, vitals, and daily weight trends

Support safe medication routines and side effect monitoring

Assess fluid status and reinforce diuretic effectiveness indicators

Screen home safety risks related to dizziness, fatigue, and falls

Coordinate ordered supplies and monitoring tools as needed

Education + Self-Management

Teach daily weight tracking and what changes mean
Reinforce low-sodium habits and practical meal choices
Coach pacing, energy conservation, and safe activity progression
Train caregivers using teach-back for confidence at home
Provide clear red-flag guidance and when to call immediately
Review fluid guidance and thirst management strategies if ordered
Encourage follow-up appointment readiness and question prompts

Care Coordination

Provide timely physician updates with clear symptom and weight trends

Request and confirm orders for medication or plan adjustments

Coordinate refills and prevent gaps in diuretics and key meds

Communicate with cardiology/PCP for escalations and follow-up needs

Align plan with discharge instructions and transition notes

Maintain consistent handoffs with referral partners and family

Why HeartStrong™

First 7 Days Workflow

Days

01 - 02

➜ Skilled nurse evaluation and heart failure risk baseline
➜ Medication reconciliation with focus on diuretics, BP meds, and interactions
➜ Confirm monitoring plan (daily weights, symptom tracking, vitals as ordered)
➜ Identify immediate risks and initiate education right away

Days

03-05

➜ Review trends and refine routine for consistency
➜ Reinforce prevention plan and fall-safety habits
➜ Update physician and confirm next-step plan

Days

06-07

➜ Re-measure wound and document trend
➜ Reinforce prevention plan (pressure relief + skin checks)
➜ Update physician on progress and confirm next-step plan

Call the nurse immediately

Red Flags We Watch

Weight gain of 2–3 lbs in 24 hours or 5 lbs in a week

Increased shortness of breath at rest, new wheezing, or trouble lying flat

New or worsening swelling in legs, ankles, abdomen, or hands

New chest discomfort, fainting, or severe dizziness (emergency if severe)

New confusion, extreme fatigue, or sudden decline in function

Reduced urine output or signs of dehydration with diuretics

HeartStrong™ OUTCOMES

Outcomes we track

ED visits and hospitalizations related to heart failure

Weight and symptom stability trends over time

Medication adherence and reduced missed doses

Patient/caregiver confidence with daily routine (quick 1–10 score)

Early escalations that prevent deterioration

HeartStrong™ CARE TEAM

Team Involved

Skilled nurse (RN/LPN per case needs and regulations)

PT/OT as appropriate for mobility, transfers, pressure relief, and safe ambulation

MSW as needed for caregiver support and resource coordination

Care Coordinator for scheduling, supply follow-up, and referral communication

Connect With Home Heal

Care Starts With a Conversation

Whether this is for you or a loved one, we’ll guide you through eligibility, timing, and what to expect, one step at a time.

Serving DuPage, Cook, and Will County. Not sure if you qualify?

Let's Figure it out