The THFC Process

Gain Insight:
The Nurse Practitioner will schedule an initial evaluation with the patient & family to evaluate the patient’s overall health including their physical, mental, social and functional well-being, in order to, identify individual health needs and develop strategies that aim to reduce symptoms, maximize function, and quality of life. At each scheduled follow-up the NP & in collaboration with a THFC physician will review overall health status and need for therapy adjustment.
Support & Coordinate:
The Nurse Practitioner and physician group will optimize medications, request & coordinate home & community services to support the patients & families in their homes. The NP will continue to follow patients and make adjustments to their therapies and coordinate home supports until such time that they are at the end of life care. At that time, patients will be referred to Palliative Care to further support their comfort & dignity.  
Plan for the Future: 

The THFC team works with patients and families to make decisions about immediate health care needs in consideration of their current state of health and available supports and resources. The team assists patients and families to identify their goals in order to make decisions for their future care through development of an Advanced Care Plan. The THFC will communicate the patient’s goals of care and facilitate Advanced Directives to other services and health professionals involved in the patient’s care.
Patients and families are encouraged to contact the NP if signs/ symptoms of heart failure worsen to allow for more urgent follow-up.