Transitional Heart Failure Clinic

The mission of the THFC is to transition patients with end-stage HF from a chronic disease management model in an ambulatory care or inpatient care setting, to a palliative model of care, in a home-based setting. The THFC is a patient-centered, evidenced-based service with a collaborative model of care including one Nurse Practitioner and a roster of interdisciplinary physicians from Internal Medicine, Geriatrics & Palliative Care.

The primary goals of the THFC are to reduce symptom burden, maintain quality of life and reduce Emergency Department usage & hospital admission for patients with end-stage heart failure who are approaching the end of life. The THFC will guide advanced care planning and assist patients to establish advanced directives in order to support their individual goals of care.